- Email: [email protected]
Fourteen years follow up of an unclassified Talar body fracture with review of literature
Foot and Ankle Surgery 12 (2006) 85–88 www.elsevier.com/locate/fas
Fourteen years follow up of an unclassified Talar body fracture with review of literature Kailash Laxman Devalia, A.H Ismaiel *, George Joseph, M. Gh Jesry Barnsley District General Hospital, Gawber Road, Barnsley, South Yorkshire S75 2EP, United Kingdom Received 11 January 2005; received in revised form 9 January 2006; accepted 17 January 2006
Abstract Talar body fractures are rare. Four major types of talar neck fractures are known but talar body fractures are rarely described. An unusual case of a sagittal fracture of the body of talus is reported in this article. No similar cases are reported in the English literature to the best of our knowledge. The risk of avascular necrosis is very high and accurate reduction with solid fixation remains the key to better outcome. We discuss the possible mechanism of injury along with review of literature. # 2006 Published by Elsevier Ltd on behalf of European Foot and Ankle Society. Keywords: Talar body fractures; Sagittal fractures; Medial malleolus; Avascular necrosis; Post-traumatic arthritis
1. Case report A 30-year-old painter fell 10 feet from a ladder, landed and twisted his right ankle. He was seen in Accident and Emergency department. Physical examination revealed a swollen tender ankle, intact skin with no neurovascular deficit. Radiographs revealed a displaced vertical fracture of the neck of the talus extending through the body with vertical fracture of the medial malleolus and medial talar shift (Figs. 1 and 2). Open reduction and internal fixation was performed through a medial approach. The Deltoid ligament was protected. The lateral half of talar dome was found rotated posteriorly along with some small loose fragments. These were removed and the fracture was fixed with two AO cancellous lag screws under image intensifier control. The medial malleolus was fixed with tension band technique (Figs. 3 and 4). The patient was discharged with a below knee non-weight bearing complete cast. On the 6th postoperative week radiographs showed increased density and subchondral lucency of the medial fragment (Fig. 5). The patient was kept non-weight bearing for another 6 weeks following which range of motion exercises were started. Partial weight bearing was allowed after three months following surgery. * Corresponding author. Tel.: +44 1226 730000 E-mail address: [email protected] (A. Ismaiel).
At 412 months patient had active ankle movements with no pain. The radiographs confirmed 43 avascular necrosis (AVN) of lateral 60% of the talus and an indentation was visible between the living and the dead bone. At six months, the fracture had healed completely. The lateral half was unchanged but the medial half had increased density to near normal (Fig. 6). The patient had active dorsiflexion of 58 and plantar flexion of 108. The radiographs taken at seventh month showed signs of revascularisation at junction of lateral and medial halves. Patient had some pain while walking but ankle and subtalar movements were normal. At 16th month, radiographs revealed early osteophytes formation at outer edge of tibial joint surface. The metal work was removed two years following the surgery. At 28 months following injury, patient had good range of movement with little pain. Radiographs showed irregular ankle joint surface (Figs. 7 and 8). The patient was discharged having been informed about the chances of arthritis in the future. At 14 years following the injury, he still had full range of movements. Recent radiographs had shown some sclerosis of the lateral fragment of talus. The joint space was well preserved and there were no signs of collapse (Figs. 9 and 10). Patient himself was very pleased with the outcome in spite of having occasional pain and swelling in the ipsilateral foot.
1268-7731/$ – see front matter # 2006 Published by Elsevier Ltd on behalf of European Foot and Ankle Society. doi:10.1016/j.fas.2006.01.003
86
K.L. Devalia et al. / Foot and Ankle Surgery 12 (2006) 85–88
Fig. 1. Pre operative AP view.
Fig. 3. Immediate post operative AP films.
Fig. 2. Pre operative lateral view.
2. Discussion Talar fractures have a relatively low incidence, accounting for 0.3% of all bone fractures and 3.4% of foot fractures [1,7]. These injuries affect the neck of the talus more than the head or body. Fractures of the body of the talus are uncommon and poorly described, accounting for 7–38% of all talus fractures
[2]. Body fractures usually affect the mechanical alignment and the congruity of both the tibiotalar and subtalar joints. A combination of talar body fracture and medial malleolus fracture is extremely rare. We could find only one case in English literature with similar injury, which was an open fracture and hence different from our case [3]. This case seems to be the only case found in the literature with a closed, vertical sagittal talar body fracture with medial malleolar involvement. A few cases have been described in which the fracture involved the lateral malleolus. The mechanism of injury in this case was most probably marked dorsiflexion with inversion. Sneppen and Buhl (1974) suggested that a medial site talar body fracture was typical of supination injury, whereas pronation-external rotation usually produces lateral site fracture [4]. The deltoid ligament exerts the restraining force on external rotation of talus when the foot is loaded on the ground [5]. The axial force is transmitted through the sagittal axis of the dome of the talus and usually produces comminution of the talar body [6]. However the additional inversion torque seems to distribute this force to the medial structures, producing a vertical split of the talar body and the medial malleolar fracture.
K.L. Devalia et al. / Foot and Ankle Surgery 12 (2006) 85–88
87
Fig. 4. Immediate post operative lateral films.
Fig. 6. AP view showing complete union.
In head and neck of the talus are supplied by branches from the anterior tibial and dorsalis pedis vessels. The main artery supplying the body of the talus is the artery of the tarsal canal
whish arises from the posterior tibial artery. Deltoid branches arise from the artery of the tarsal canal and supplies the medial third of the body of talus. A sagittal fracture therefore devascularises the lateral portion of the talar dome as the only remaining blood supply after displacement is through the deltoid branches entering the body medially. Union of the fracture in such case is extremely slow as it depends on a new blood supply growing into the avascular bone. This process of revascularisation can be enhanced by accurate and stable reduction of the fracture [2]. Rates of osteonecrosis of as high as 40% have been reported after talar body fractures [4,7,8].
Fig. 5. AP view showing AVN of lateral fragment.
Fig. 7. Final AP view after implant removal.
88
K.L. Devalia et al. / Foot and Ankle Surgery 12 (2006) 85–88
Fig. 8. Final lateral view after implant removal.
Fig. 10. Lateral view 14 years following surgery.
blood supply in the injury. The pattern of avascular necrosis of the lateral fragment seems to coincide with the usual pattern of the blood supply to the talus. However, there was no evidence of collapse or early post-traumatic osteoarthrosis at reasonably long follow up. Despite considerable disagreement within the literature, it seems that accurate, rigid fixation of fragments with protection in a non-weight bearing cast may prevent the risk of avascular necrosis and collapse. We would recommend non-weight bearing in similar cases guided by the radiological evidence of bone union.
References
Fig. 9. AP view 14 years following surgery.
The risk of collapse is greater but may be prevented by protecting the fixation for a long time as observed in our case [2]. The risk of post-traumatic arthritis in the ankle and subtalar joints is usually unpreventable. The outcome of our case was less severe than originally expected (Figs. 9 and 10). The talus was united with satisfactory congruity and preservation of the ankle and subtalar joint movements. The lateral part of the talus lost its
[1] Rottcher T, Lange K, Reinbold WD, et al. Sagittal burst fracture of the talus. Radiologe 1994;34(12):759–61. [2] Vallier HA, Nork SE, Benirschke SK. Surgical Treatment of Talar Body Fractures. J Bone Joint Surg Am 2003;85(9):1716–24. [3] ‘‘Unusual ankle injury’’ Shah K, http://www.edu.rcsed.ac.uk/Case Presentations/CP20.htm. [4] Sneppen O, Christensen SB, Krogsoe O, et al. Fracture of the body of the Talus. Acta Orthop Scand 1977;48:317–24. [5] Michelsen JD, Ahn UM, Helgemo SL. Motion of the ankle in a simulated supination-external rotation fracture model. J Bone Joint Surg Am 1996;78(7):1024–31. [6] Thordarson DB. Talar body fractures. Orthop Clin North Am 2001;32(1):65–77. [7] Coltart WD. Aviator’s astragalus. J Bone Joint Surg 1952;34-B:545–66. [8] Szyskowitz R, Reschauer R, Seggl W. Eighty-five Talus fractures treated by ORIF with five to eight years of follow-up study of 69 patients. Clin Orthop 1985; 1990:97–107.
Fourteen years follow up of an unclassified Talar body fracture with review of literature Kailash Laxman Devalia, A.H Ismaiel *, George Joseph, M. Gh Jesry Barnsley District General Hospital, Gawber Road, Barnsley, South Yorkshire S75 2EP, United Kingdom Received 11 January 2005; received in revised form 9 January 2006; accepted 17 January 2006
Abstract Talar body fractures are rare. Four major types of talar neck fractures are known but talar body fractures are rarely described. An unusual case of a sagittal fracture of the body of talus is reported in this article. No similar cases are reported in the English literature to the best of our knowledge. The risk of avascular necrosis is very high and accurate reduction with solid fixation remains the key to better outcome. We discuss the possible mechanism of injury along with review of literature. # 2006 Published by Elsevier Ltd on behalf of European Foot and Ankle Society. Keywords: Talar body fractures; Sagittal fractures; Medial malleolus; Avascular necrosis; Post-traumatic arthritis
1. Case report A 30-year-old painter fell 10 feet from a ladder, landed and twisted his right ankle. He was seen in Accident and Emergency department. Physical examination revealed a swollen tender ankle, intact skin with no neurovascular deficit. Radiographs revealed a displaced vertical fracture of the neck of the talus extending through the body with vertical fracture of the medial malleolus and medial talar shift (Figs. 1 and 2). Open reduction and internal fixation was performed through a medial approach. The Deltoid ligament was protected. The lateral half of talar dome was found rotated posteriorly along with some small loose fragments. These were removed and the fracture was fixed with two AO cancellous lag screws under image intensifier control. The medial malleolus was fixed with tension band technique (Figs. 3 and 4). The patient was discharged with a below knee non-weight bearing complete cast. On the 6th postoperative week radiographs showed increased density and subchondral lucency of the medial fragment (Fig. 5). The patient was kept non-weight bearing for another 6 weeks following which range of motion exercises were started. Partial weight bearing was allowed after three months following surgery. * Corresponding author. Tel.: +44 1226 730000 E-mail address: [email protected] (A. Ismaiel).
At 412 months patient had active ankle movements with no pain. The radiographs confirmed 43 avascular necrosis (AVN) of lateral 60% of the talus and an indentation was visible between the living and the dead bone. At six months, the fracture had healed completely. The lateral half was unchanged but the medial half had increased density to near normal (Fig. 6). The patient had active dorsiflexion of 58 and plantar flexion of 108. The radiographs taken at seventh month showed signs of revascularisation at junction of lateral and medial halves. Patient had some pain while walking but ankle and subtalar movements were normal. At 16th month, radiographs revealed early osteophytes formation at outer edge of tibial joint surface. The metal work was removed two years following the surgery. At 28 months following injury, patient had good range of movement with little pain. Radiographs showed irregular ankle joint surface (Figs. 7 and 8). The patient was discharged having been informed about the chances of arthritis in the future. At 14 years following the injury, he still had full range of movements. Recent radiographs had shown some sclerosis of the lateral fragment of talus. The joint space was well preserved and there were no signs of collapse (Figs. 9 and 10). Patient himself was very pleased with the outcome in spite of having occasional pain and swelling in the ipsilateral foot.
1268-7731/$ – see front matter # 2006 Published by Elsevier Ltd on behalf of European Foot and Ankle Society. doi:10.1016/j.fas.2006.01.003
86
K.L. Devalia et al. / Foot and Ankle Surgery 12 (2006) 85–88
Fig. 1. Pre operative AP view.
Fig. 3. Immediate post operative AP films.
Fig. 2. Pre operative lateral view.
2. Discussion Talar fractures have a relatively low incidence, accounting for 0.3% of all bone fractures and 3.4% of foot fractures [1,7]. These injuries affect the neck of the talus more than the head or body. Fractures of the body of the talus are uncommon and poorly described, accounting for 7–38% of all talus fractures
[2]. Body fractures usually affect the mechanical alignment and the congruity of both the tibiotalar and subtalar joints. A combination of talar body fracture and medial malleolus fracture is extremely rare. We could find only one case in English literature with similar injury, which was an open fracture and hence different from our case [3]. This case seems to be the only case found in the literature with a closed, vertical sagittal talar body fracture with medial malleolar involvement. A few cases have been described in which the fracture involved the lateral malleolus. The mechanism of injury in this case was most probably marked dorsiflexion with inversion. Sneppen and Buhl (1974) suggested that a medial site talar body fracture was typical of supination injury, whereas pronation-external rotation usually produces lateral site fracture [4]. The deltoid ligament exerts the restraining force on external rotation of talus when the foot is loaded on the ground [5]. The axial force is transmitted through the sagittal axis of the dome of the talus and usually produces comminution of the talar body [6]. However the additional inversion torque seems to distribute this force to the medial structures, producing a vertical split of the talar body and the medial malleolar fracture.
K.L. Devalia et al. / Foot and Ankle Surgery 12 (2006) 85–88
87
Fig. 4. Immediate post operative lateral films.
Fig. 6. AP view showing complete union.
In head and neck of the talus are supplied by branches from the anterior tibial and dorsalis pedis vessels. The main artery supplying the body of the talus is the artery of the tarsal canal
whish arises from the posterior tibial artery. Deltoid branches arise from the artery of the tarsal canal and supplies the medial third of the body of talus. A sagittal fracture therefore devascularises the lateral portion of the talar dome as the only remaining blood supply after displacement is through the deltoid branches entering the body medially. Union of the fracture in such case is extremely slow as it depends on a new blood supply growing into the avascular bone. This process of revascularisation can be enhanced by accurate and stable reduction of the fracture [2]. Rates of osteonecrosis of as high as 40% have been reported after talar body fractures [4,7,8].
Fig. 5. AP view showing AVN of lateral fragment.
Fig. 7. Final AP view after implant removal.
88
K.L. Devalia et al. / Foot and Ankle Surgery 12 (2006) 85–88
Fig. 8. Final lateral view after implant removal.
Fig. 10. Lateral view 14 years following surgery.
blood supply in the injury. The pattern of avascular necrosis of the lateral fragment seems to coincide with the usual pattern of the blood supply to the talus. However, there was no evidence of collapse or early post-traumatic osteoarthrosis at reasonably long follow up. Despite considerable disagreement within the literature, it seems that accurate, rigid fixation of fragments with protection in a non-weight bearing cast may prevent the risk of avascular necrosis and collapse. We would recommend non-weight bearing in similar cases guided by the radiological evidence of bone union.
References
Fig. 9. AP view 14 years following surgery.
The risk of collapse is greater but may be prevented by protecting the fixation for a long time as observed in our case [2]. The risk of post-traumatic arthritis in the ankle and subtalar joints is usually unpreventable. The outcome of our case was less severe than originally expected (Figs. 9 and 10). The talus was united with satisfactory congruity and preservation of the ankle and subtalar joint movements. The lateral part of the talus lost its
[1] Rottcher T, Lange K, Reinbold WD, et al. Sagittal burst fracture of the talus. Radiologe 1994;34(12):759–61. [2] Vallier HA, Nork SE, Benirschke SK. Surgical Treatment of Talar Body Fractures. J Bone Joint Surg Am 2003;85(9):1716–24. [3] ‘‘Unusual ankle injury’’ Shah K, http://www.edu.rcsed.ac.uk/Case Presentations/CP20.htm. [4] Sneppen O, Christensen SB, Krogsoe O, et al. Fracture of the body of the Talus. Acta Orthop Scand 1977;48:317–24. [5] Michelsen JD, Ahn UM, Helgemo SL. Motion of the ankle in a simulated supination-external rotation fracture model. J Bone Joint Surg Am 1996;78(7):1024–31. [6] Thordarson DB. Talar body fractures. Orthop Clin North Am 2001;32(1):65–77. [7] Coltart WD. Aviator’s astragalus. J Bone Joint Surg 1952;34-B:545–66. [8] Szyskowitz R, Reschauer R, Seggl W. Eighty-five Talus fractures treated by ORIF with five to eight years of follow-up study of 69 patients. Clin Orthop 1985; 1990:97–107.