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Talar body fracture associated with unrecognised talocalcaneal coalition
Foot and Ankle Surgery 16 (2010) e4–e7
Contents lists available at ScienceDirect
Foot and Ankle Surgery journal homepage: www.elsevier.com/locate/fas
Case report
Talar body fracture associated with unrecognised talocalcaneal coalition Adrian Hughes M.B., B.S., M.A., M.R.C.S. Enga, Rick Brown M.A., F.R.C.S.(Tr & Orth)b,* a b
Painswick Coach House, 64 Suffolk Road, Cheltenham GL50 2AQ, United Kingdom Department of Trauma and Orthopaedics, Cheltenham General Hospital, Sandford Road, Cheltenham GL53 7AN, United Kingdom
A R T I C L E I N F O
A B S T R A C T
Article history: Received 19 May 2008 Received in revised form 5 February 2009 Accepted 13 February 2009
We report the case of a talar body fracture occurring in association with a previously undiagnosed talocalcaneal coalition. A rotational injury during a football tackle produced a grossly deformed ankle that was reduced in the emergency department. The unusual appearance of the medial sub-talar region on plain radiographs prompted further imaging by computerised tomography, which confirmed an osseous talocalcaneal coalition. Operative findings included a talar body fracture that could only be reduced after excision of the osseous coalition. The fracture was reduced and fixed. The patient made a good postoperative recovery with favourable AOFAS scores in the medium term at 1 year. ß 2009 European Foot and Ankle Society. Published by Elsevier Ltd. All rights reserved.
Keywords: Talar body fracture Talocalcaneal coalition
1. Introduction Talocalcaneal coalitions are uncommon [1], while fractures of the talar body account for only 18% of talar fractures in one series of 60 such fractures [2]. Therefore they are unlikely to occur together. There has been a case report of a calcaneal fracture occurring with a talocalcaneal coalition [3]. However to our knowledge this case report is the first of a talar body fracture in this condition. 2. Case report A 32-year-old male sustained a rotational injury to his ankle during a heavy tackle while playing football and presented to the emergency department complaining of pain and an inability to weight bear. Initial clinical assessment showed a grossly deformed ankle which was reduced under sedation in the emergency department before radiographs were taken. On clinical grounds this was likely to involve a sub-talar subluxation. There was no pre-existing history of a flat foot or recurrent ankle ligament sprains. Plain radiographs excluded fractures of the distal tibia and fibula (Fig. 1a and b). The unusual radiographic appearance of the medial sub-talar joint was further imaged by computerised tomography (Fig. 2a–d). This showed an osseous coalition across the middle facet of the sub-talar joint between the medial talus with the sustentaculum tali. A vertical fracture line passed through
* Corresponding author. Tel.: +44 8454 222322; fax: +44 8454 223615. E-mail addresses: [email protected] (A. Hughes), [email protected] (R. Brown).
the posterior third of the talar body with the fracture line passing into the osseous coalition. The postero-medial fragment was displaced 7 mm medially and 7 mm posteriorly. Surgery was performed under tourniquet through a posteromedial incision. The displaced fragment could be moved by inversion of the sub-talar joint, but complete reduction of the fragment was prevented by the talocalcaneal coalition. After retracting the tibialis posterior tendon anteriorly and incising the flexor retinaculum, the coalition was exposed and found to be composed of osseous material. The postero-medial fragment could only be anatomically reduced after excision of this coalition. It was fixed with two 4 mm diameter partially threaded cancellous screws (Biomet). The gap across the sub-talar joint was a minimum of 5 mm and packed with muscle tissue from the abductor hallucis brevis. Standard wound closure was in layers. The wound healed without any skin complication in a below knee POP for 2 weeks. For the next 4 weeks he was non-weight bearing in a removable walker (aircast1) boot and allowed to perform initial gentle hind foot plantar-flexion exercises. The fracture reduction remained satisfactory on the radiographs 6 weeks after surgery (Fig. 3a and b). He then was partial weight bearing (50% body weight) for a further 6 weeks with unlimited range of movement exercises. At follow-up after 1 year the patient’s AOFAS Hind foot Score was 87. The hind foot motion had moderate restriction. The patient has returned to sports such as cycling. The CT showed no evidence of osteonecrosis of the operated talus (Fig. 4a). The AOFAS score was similar to his contra-lateral non-operated hind foot, which also lacked 50% of inversion/eversion. This could be attribute to another asymptomatic talocalcaneal coalition confirmed on a further CT scan (Fig. 4b).
1268-7731/$ – see front matter ß 2009 European Foot and Ankle Society. Published by Elsevier Ltd. All rights reserved. doi:10.1016/j.fas.2009.02.004
A. Hughes, R. Brown / Foot and Ankle Surgery 16 (2010) e4–e7
e5
Fig. 1. (a and b) Lateral and AP views of the ankle after closed reduction in the emergency department. The lack of fractures of tibia or fibula, as well as the appearance of the medial sub-talar joint prompted further imaging with C.T.
Fig. 2. (a–d) Computerised tomography. (a) Transverse view showing the osseous talocalaneal coalition; (b) sagital view showing the coalition as well as a fracture of the medial talar body; (c and d) transverse and coronal view showing the talar body fracture.
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A. Hughes, R. Brown / Foot and Ankle Surgery 16 (2010) e4–e7
Fig. 3. (a and b) AP and lateral plain radiographs of the ankle 6 weeks postoperatively.
Fig. 4. (a and b) Computerised tomography. (a) Coronal view showing the right hind foot 1 year after surgery and (b) coronal view showing another coalition on the opposite side.
3. Discussion Although a talocalcaneal coalition can occur between any of the three facets of the sub-talar joint, they are characteristically across the middle facet involving the medial side of the sub-talar joint [4]. Talocalcaneal coalitions are often unrecognised until becoming symptomatic in early teenage years when the pre-existing cartilaginous bridge ossifies [5]. Attempted forced inversion can lead to repeated lateral ankle ligament sprains preventing participation in sports.
A comprehensive literature search found a single case report of a low energy injury to a patient with a talocalcaneal coalition leading to a displaced intra-articular fracture of the calcaneum associated with a fibrous coalition of the middle facet [3]. In addition, a fracture of the talar beak has been reported with tarsal coalitions [6]. Until now a talar body fracture has not been reported in association with a talocalcaneal coalition. A postero-medial approach was chosen as this has been shown to give good access to the relatively rare postero-medial talar fracture [7]. This same study showed that after an average follow-
A. Hughes, R. Brown / Foot and Ankle Surgery 16 (2010) e4–e7
up of 4.5 years from surgical fixation of a postero-medial talar body fracture, no patient had undergone arthrodesis at the time of follow-up. However the prognosis must be cautious and long term follow-up is advised, because talar body fractures are associated with a high risk of post-traumatic arthritis or avascular necrosis. Vallier et al. reported that 88% of patients had radiographic evidence of post-traumatic arthritis and/or osteonecrosis [8]. The alternative management of fixation of the fracture and primary fusion of the sub-talar joint was considered but rejected as the patient was previously asymptomatic, the coalition covered less than 40% of the surface area of the sub-talar joint and the CT scan excluded evidence of early degenerative changes. 4. Conclusions A low energy injury in a patient with an unrecognised talocalcaneal coalition can result in fracture through the talar body. This is a rare and previously unreported injury. This may not be clearly visible on a radiograph, but can be detected by CT scanning. To allow reduction of the displaced talar body fracture the osseous
e7
coalition must be excised. If there is no early sub-talar joint degeneration and the coalition bridges less than 40% of the joint surface area, a good medium term outcome can be achieved by reduction and fixation and primary sub-talar fusion can be avoided. References [1] Stormont DM, Peterson HA. The relative incidence of tarsal coalition. Clin Orthop 1983;181:28–36. [2] Elgafy H, Ebraheim NA, Tile M, Stephen D, Kase J. Fractures of the talus: experience of two, level 1 trauma centers. Foot Ankle Int 2000;21(12):1023–9. [3] Kim DH, Berkowitz MJ. Fracture of the calcaneus associated with talocalcaneal coalition. Foot Ankle Int 2004;25(6):426–8. [4] Comfort TK, Johnson LO. Resection for symptomatic Talocalcaneal Coalition. J Paed Orthop 1998;18:283–8. [5] Blakemore LC, Cooperman DR, Thompson GH. The rigid flatfoot. Tarsal coalitions. Clin Pediatr Med Surg 2000;17(3):531–55. [6] Resnik CS, Aiken MW, Kenzora JE. Fracture of talar beaks in tarsal coalition. Skeletal Radiol 1993;22(3):214–7. [7] Swords MP, Benirschke S, Greisberg J, Shank J. Posteromedial talar body fractures: surgical technique and results in ten patients. In: Read at the annual summer meeting of the American Orthopaedic Foot and Ankle Society; 2005. [8] Vallier HA, Nork SE, Benirschke SK, Sangeorzan BJ. Surgical treatment of talar body fractures. J Bone Joint Surg (Am) 2004;86(Suppl. 1):180–92.
Contents lists available at ScienceDirect
Foot and Ankle Surgery journal homepage: www.elsevier.com/locate/fas
Case report
Talar body fracture associated with unrecognised talocalcaneal coalition Adrian Hughes M.B., B.S., M.A., M.R.C.S. Enga, Rick Brown M.A., F.R.C.S.(Tr & Orth)b,* a b
Painswick Coach House, 64 Suffolk Road, Cheltenham GL50 2AQ, United Kingdom Department of Trauma and Orthopaedics, Cheltenham General Hospital, Sandford Road, Cheltenham GL53 7AN, United Kingdom
A R T I C L E I N F O
A B S T R A C T
Article history: Received 19 May 2008 Received in revised form 5 February 2009 Accepted 13 February 2009
We report the case of a talar body fracture occurring in association with a previously undiagnosed talocalcaneal coalition. A rotational injury during a football tackle produced a grossly deformed ankle that was reduced in the emergency department. The unusual appearance of the medial sub-talar region on plain radiographs prompted further imaging by computerised tomography, which confirmed an osseous talocalcaneal coalition. Operative findings included a talar body fracture that could only be reduced after excision of the osseous coalition. The fracture was reduced and fixed. The patient made a good postoperative recovery with favourable AOFAS scores in the medium term at 1 year. ß 2009 European Foot and Ankle Society. Published by Elsevier Ltd. All rights reserved.
Keywords: Talar body fracture Talocalcaneal coalition
1. Introduction Talocalcaneal coalitions are uncommon [1], while fractures of the talar body account for only 18% of talar fractures in one series of 60 such fractures [2]. Therefore they are unlikely to occur together. There has been a case report of a calcaneal fracture occurring with a talocalcaneal coalition [3]. However to our knowledge this case report is the first of a talar body fracture in this condition. 2. Case report A 32-year-old male sustained a rotational injury to his ankle during a heavy tackle while playing football and presented to the emergency department complaining of pain and an inability to weight bear. Initial clinical assessment showed a grossly deformed ankle which was reduced under sedation in the emergency department before radiographs were taken. On clinical grounds this was likely to involve a sub-talar subluxation. There was no pre-existing history of a flat foot or recurrent ankle ligament sprains. Plain radiographs excluded fractures of the distal tibia and fibula (Fig. 1a and b). The unusual radiographic appearance of the medial sub-talar joint was further imaged by computerised tomography (Fig. 2a–d). This showed an osseous coalition across the middle facet of the sub-talar joint between the medial talus with the sustentaculum tali. A vertical fracture line passed through
* Corresponding author. Tel.: +44 8454 222322; fax: +44 8454 223615. E-mail addresses: [email protected] (A. Hughes), [email protected] (R. Brown).
the posterior third of the talar body with the fracture line passing into the osseous coalition. The postero-medial fragment was displaced 7 mm medially and 7 mm posteriorly. Surgery was performed under tourniquet through a posteromedial incision. The displaced fragment could be moved by inversion of the sub-talar joint, but complete reduction of the fragment was prevented by the talocalcaneal coalition. After retracting the tibialis posterior tendon anteriorly and incising the flexor retinaculum, the coalition was exposed and found to be composed of osseous material. The postero-medial fragment could only be anatomically reduced after excision of this coalition. It was fixed with two 4 mm diameter partially threaded cancellous screws (Biomet). The gap across the sub-talar joint was a minimum of 5 mm and packed with muscle tissue from the abductor hallucis brevis. Standard wound closure was in layers. The wound healed without any skin complication in a below knee POP for 2 weeks. For the next 4 weeks he was non-weight bearing in a removable walker (aircast1) boot and allowed to perform initial gentle hind foot plantar-flexion exercises. The fracture reduction remained satisfactory on the radiographs 6 weeks after surgery (Fig. 3a and b). He then was partial weight bearing (50% body weight) for a further 6 weeks with unlimited range of movement exercises. At follow-up after 1 year the patient’s AOFAS Hind foot Score was 87. The hind foot motion had moderate restriction. The patient has returned to sports such as cycling. The CT showed no evidence of osteonecrosis of the operated talus (Fig. 4a). The AOFAS score was similar to his contra-lateral non-operated hind foot, which also lacked 50% of inversion/eversion. This could be attribute to another asymptomatic talocalcaneal coalition confirmed on a further CT scan (Fig. 4b).
1268-7731/$ – see front matter ß 2009 European Foot and Ankle Society. Published by Elsevier Ltd. All rights reserved. doi:10.1016/j.fas.2009.02.004
A. Hughes, R. Brown / Foot and Ankle Surgery 16 (2010) e4–e7
e5
Fig. 1. (a and b) Lateral and AP views of the ankle after closed reduction in the emergency department. The lack of fractures of tibia or fibula, as well as the appearance of the medial sub-talar joint prompted further imaging with C.T.
Fig. 2. (a–d) Computerised tomography. (a) Transverse view showing the osseous talocalaneal coalition; (b) sagital view showing the coalition as well as a fracture of the medial talar body; (c and d) transverse and coronal view showing the talar body fracture.
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A. Hughes, R. Brown / Foot and Ankle Surgery 16 (2010) e4–e7
Fig. 3. (a and b) AP and lateral plain radiographs of the ankle 6 weeks postoperatively.
Fig. 4. (a and b) Computerised tomography. (a) Coronal view showing the right hind foot 1 year after surgery and (b) coronal view showing another coalition on the opposite side.
3. Discussion Although a talocalcaneal coalition can occur between any of the three facets of the sub-talar joint, they are characteristically across the middle facet involving the medial side of the sub-talar joint [4]. Talocalcaneal coalitions are often unrecognised until becoming symptomatic in early teenage years when the pre-existing cartilaginous bridge ossifies [5]. Attempted forced inversion can lead to repeated lateral ankle ligament sprains preventing participation in sports.
A comprehensive literature search found a single case report of a low energy injury to a patient with a talocalcaneal coalition leading to a displaced intra-articular fracture of the calcaneum associated with a fibrous coalition of the middle facet [3]. In addition, a fracture of the talar beak has been reported with tarsal coalitions [6]. Until now a talar body fracture has not been reported in association with a talocalcaneal coalition. A postero-medial approach was chosen as this has been shown to give good access to the relatively rare postero-medial talar fracture [7]. This same study showed that after an average follow-
A. Hughes, R. Brown / Foot and Ankle Surgery 16 (2010) e4–e7
up of 4.5 years from surgical fixation of a postero-medial talar body fracture, no patient had undergone arthrodesis at the time of follow-up. However the prognosis must be cautious and long term follow-up is advised, because talar body fractures are associated with a high risk of post-traumatic arthritis or avascular necrosis. Vallier et al. reported that 88% of patients had radiographic evidence of post-traumatic arthritis and/or osteonecrosis [8]. The alternative management of fixation of the fracture and primary fusion of the sub-talar joint was considered but rejected as the patient was previously asymptomatic, the coalition covered less than 40% of the surface area of the sub-talar joint and the CT scan excluded evidence of early degenerative changes. 4. Conclusions A low energy injury in a patient with an unrecognised talocalcaneal coalition can result in fracture through the talar body. This is a rare and previously unreported injury. This may not be clearly visible on a radiograph, but can be detected by CT scanning. To allow reduction of the displaced talar body fracture the osseous
e7
coalition must be excised. If there is no early sub-talar joint degeneration and the coalition bridges less than 40% of the joint surface area, a good medium term outcome can be achieved by reduction and fixation and primary sub-talar fusion can be avoided. References [1] Stormont DM, Peterson HA. The relative incidence of tarsal coalition. Clin Orthop 1983;181:28–36. [2] Elgafy H, Ebraheim NA, Tile M, Stephen D, Kase J. Fractures of the talus: experience of two, level 1 trauma centers. Foot Ankle Int 2000;21(12):1023–9. [3] Kim DH, Berkowitz MJ. Fracture of the calcaneus associated with talocalcaneal coalition. Foot Ankle Int 2004;25(6):426–8. [4] Comfort TK, Johnson LO. Resection for symptomatic Talocalcaneal Coalition. J Paed Orthop 1998;18:283–8. [5] Blakemore LC, Cooperman DR, Thompson GH. The rigid flatfoot. Tarsal coalitions. Clin Pediatr Med Surg 2000;17(3):531–55. [6] Resnik CS, Aiken MW, Kenzora JE. Fracture of talar beaks in tarsal coalition. Skeletal Radiol 1993;22(3):214–7. [7] Swords MP, Benirschke S, Greisberg J, Shank J. Posteromedial talar body fractures: surgical technique and results in ten patients. In: Read at the annual summer meeting of the American Orthopaedic Foot and Ankle Society; 2005. [8] Vallier HA, Nork SE, Benirschke SK, Sangeorzan BJ. Surgical treatment of talar body fractures. J Bone Joint Surg (Am) 2004;86(Suppl. 1):180–92.