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Talus avulsion fractures: Are they accurately diagnosed?
G Model
JINJ-6277; No. of Pages 3 Injury, Int. J. Care Injured xxx (2015) xxx–xxx
Contents lists available at ScienceDirect
Injury journal homepage: www.elsevier.com/locate/injury
Talus avulsion fractures: Are they accurately diagnosed? Karen P. Robinson *, Mark B. Davies Northern General Hospital, Sheffield Teaching Hospitals NHS Trust, Herries Road, Sheffield S5 7AU, United Kingdom
A R T I C L E I N F O
A B S T R A C T
Article history: Accepted 29 June 2015
Dorsal talus avulsion fractures occurring along the supination line of the foot can cause pain and discomfort. Examination of the foot and ankle using the Ottawa ankle rules does not include examination of the talus, an injury here is easily missed causing concern to the patient. This is a retrospective study carried out in a major trauma centre to look at the assessment and diagnosis of all patients with a dorsal talus and navicular avulsion fractures over a one year period. Nineteen patients with an isolated dorsal talus avulsion fracture and five patients with an isolated dorsal navicular fracture were included. The correct diagnosis was made in 12 of patients with isolated dorsal talus avulsion fractures, 7 patients were given an incorrect diagnosis after misreading of the radiograph. Four patients with a dorsal navicular avulsion fracture were given the correct diagnosis. If not correctly diagnosed on presentation patients can be overly concerned that a ‘fracture was missed’ which can lead to confusion and anxiety. Therefore these injuries need to be recognised early, promptly diagnosed, treated symptomatically and reassurance given. We recommend the routine palpation of the talus in addition to the examination set out in the Ottawa Ankle Rules and the close inspection of plain radiographs to adequately diagnose an injury in this area. ß 2015 Elsevier Ltd. All rights reserved.
Keywords: Talus avulsion fracture Ottawa ankle rules Supination line Inversion injuries Ankle sprain
Introduction The supination line of the foot is described as the line dividing the hindfoot and the midfoot. It is the line of rotation that injuries occur along when the foot is forced into supination, or hyper plantarflexion (Fig. 1). There can be bony or ligamentous injury occurring along this line. The dorsal talonavicular ligament and the anterior tibiotalar ligament insert onto the extra articular dorsal surface of the talus (Fig. 2) and when injured can avulse causing a small bony injury (Fig. 3). Dorsal avulsion fractures are considered insignificant [1], but patients presenting with a swollen, bruised and painful foot following an injury are often concerned and seek a diagnosis. The Ottawa Ankle rules were first introduced in 1992 [2]. They were introduced to aid clinicians in their decision making following ankle injuries with an aim of reducing radiography. The rules were validated to be 100% sensitive with a radiography reduction rate of 30–40% [3]. The Ottawa Ankle Rules split the foot and ankle into the malleolar section and the midfoot section by an imaginary line through the talonavicluar joint. Clinicians are encouraged to palpate the distal 6 cm of the fibula and medial
* Corresponding author. Tel.: +44 0114 2434343. E-mail address: [email protected] (K.P. Robinson).
malleolus, the navicular and the base of the 5th metatarsal as these are areas prone to injury with an inversion injury of the ankle [4]. Other areas along the supination line including the talus are not part of the recommended clinical examination according to these rules. The purpose of this study was to address three questions; how common talus avulsion fractures are compared with avulsion fractures of the navicular in our institution? Are talus avulsion fractures adequately identified at presentation? Does the exclusion of talus examination from the OTTAWA ankle rules lead to these fractures being missed? Methods This is a retrospective study carried out in a Major Trauma Centre looking at a one year period. The study was agreed by the local ‘clinical effectiveness unit’. All plain radiographs in our Trust are reported by a radiologist, therefore the radiology database of our hospital was searched using the terms ‘Talus AND Avulsion’, ‘Navicular AND Avulsion’, ‘Talus fracture’ and ‘Navicular fracture’ to identify all patients who had a radiographic diagnosis of an avulsion fracture of the talus, navicular or both between 1st January 2013 and 1st January 2014. The radiographs of all those listed were reviewed to confirm the diagnosis.
http://dx.doi.org/10.1016/j.injury.2015.06.041 0020–1383/ß 2015 Elsevier Ltd. All rights reserved.
Please cite this article in press as: Robinson KP, Davies MB. Talus avulsion fractures: Are they accurately diagnosed? Injury (2015), http://dx.doi.org/10.1016/j.injury.2015.06.041
G Model
JINJ-6277; No. of Pages 3 K.P. Robinson, M.B. Davies / Injury, Int. J. Care Injured xxx (2015) xxx–xxx
2
Fig. 1. Midfoot supination line.
Information detailing; mechanism of injury, weight bearing status on presentation, examination findings, diagnosis made, and subsequent management was collected. Patients involved in major trauma or transferred from another hospital were excluded.
Results Twenty-two patients with an isolated dorsal talus avulsion fracture were identified (Fig. 4). Two patients were excluded from the study, one patient was involved in a major trauma and transferred from another hospital and one patient had an associated distal fibula fracture. Of the remaining 20 patients, 19 sets of notes were available for analysis. Three patients had avulsion fractures of both the dorsal talus and dorsal aspects of the navicular. Two sets of notes were available for analysis. Seven patients had an isolated dorsal navicular avulsion fracture. Five sets of notes were available for analysis. Overall, 15 patients sustained an inversion injury, 6 patients fell downstairs, 2 patients described a simple fall, one tripped in a pot hole, one tripped over a bar on the ground and one had a crush injury. Seven patients were non-weight bearing on presentation, 10 were partially weight bearing and 1 full weight bearing. Thirteen patients had a plain radiograph of the affected ankle, five had a radiograph of the affected foot. The majority of patients presented with pain and swelling of the ankle, with lateral and medial malleolus pain on palpation. In all cases the talus was either not recorded as examined or the ‘midfoot’ was recorded as a single structure. The correct diagnosis was made in 12 patients with isolated dorsal talus avulsion fractures, 7 patients were given an incorrect diagnosis after misreading of the radiograph. Four patients with a dorsal navicular avulsion fracture were given the correct diagnosis. One patient with both a talus and navicular avulsion fracture was misdiagnosed.
Fig. 2. Diagram illustrating the ligaments of the dorsal and medial aspect of the foot.
Of the 7 patients misdiagnosed, 6 were diagnosed with a nonspecific ‘ankle sprain’, with 4 of them documented as no fracture seen. One was diagnosed with a 3rd metatarsal fracture. Two patients represented after the pain and swelling failed to settle, repeat investigations were carried out and the avulsion fracture diagnosed. The remaining patients were recalled to fracture clinic following formal reporting of the radiographs by a Radiologist. All of the patients were partial weight bearing on presentation and 3 of them had swelling but no bony tenderness on palpation.
Fig. 3. Radiograph of avulsion fracture of the talus (white arrow).
Please cite this article in press as: Robinson KP, Davies MB. Talus avulsion fractures: Are they accurately diagnosed? Injury (2015), http://dx.doi.org/10.1016/j.injury.2015.06.041
G Model
JINJ-6277; No. of Pages 3 K.P. Robinson, M.B. Davies / Injury, Int. J. Care Injured xxx (2015) xxx–xxx
3
Fig. 4. Distribution of fracture patterns.
Discussion Supination line fractures of the foot and ankle are easily missed. Schepers et al. [5] reported that dorsal avulsion fractures of the talus account for approximately 1% of all sprains, compared with 2% for navicular fractures. Similarly, Fallat et al. [6] studied 639 patients presenting with ankle sprains, 96 of them involved an osseous injury, 0.5% of these were dorsal talus avulsion fractures and 0.5% were navicular avulsion fractures. In our study, dorsal avulsion fractures were seen more frequently than navicular fractures in a one year period. Sixty three percent of these injuries were correctly diagnosed compared to over 60% misdiagnosis of these injuries reported by Schepers et al. [5]. The dorsal talonavicluar ligament and the anterior tibiotalar ligament are attached to the extra-articular dorsal surface of the talus, but the anterior tibiotalar ligament is poorly described. Milner et al. [7] and Campbell et al. [8] have studied the anatomy of the medial ligaments of the ankle. Both concluded that the tibionavicular, tibiospring and deep posterior tibiotalar ligaments are constant anatomical structures but there is variation in the presence of the deep anterior tibiotalar ligament that inserts into the talus with the dorsal talonavicular ligament. The medial ligament structures are easily injured and it may be the presence of this structure which makes an avulsion fracture of the talus more likely. Talus avulsion fractures are stable injuries that warrant no specific management and are therefore widely considered as insignificant. The supination line is line which runs through the line or articulation of the talus and navicular (Fig. 1). The omission of examination of the talus from the Ottawa Ankle rules can lead to its neglect during examination. Clinicians need a sound anatomical knowledge and routine structured examination of the foot and ankle to ensure an accurate assessment is carried out. Judd [9] comments that talar dome injuries are likely to be diagnosed by following the Ottawa ankle rules due to an inability for the patient to weight bear, but this is not always the case and extra care should be taken when assessing the patient. Extra-articular talus fractures are less of a problem, but patients with a foot injury, resulting in a grossly swollen foot that is not improving are rightly worried. If not correctly diagnosed on presentation they can be overly concerned that a ‘fracture was missed’ which can lead to confusion and anxiety. Therefore these injuries need to be recognised early, promptly diagnosed, treated symptomatically and reassurance given. Further imaging in these injuries is rarely required, a CT scan may be appropriate if there is suspicion of a bigger injury to the foot, presenting as a large clinically bruised and swollen foot out of
proportion to radiographic findings or if plain radiographs suggests midfoot instability. Fallat et al. [6] suggest that defining these often complex injuries as an ankle sprain syndrome would help clinical assessment and accuracy by encouraging a more thorough examination. Conclusion The Ottawa ankle rules are a sound clinical recommendation and an aid to identify the need for plain radiographs of the foot and ankle after trauma. Clinicians need to develop a secure anatomical knowledge of the foot and ankle and a routine structured examination to include palpation of the talus in conjunction with the principles set out in the Ottawa ankle rules. Close inspection of plain radiographs, if requested, is necessary to adequately diagnose an injury around the supination line. Conflict of interest The authors have no conflicts of interest to declare. Acknowledgements Foot and ankle illustration (Figs. 1 and 2) by Mr. Grant Lynas. References [1] Auletta AG, Conway WF, Hayes CW, Guisto DF, Gervin AS. Indications for radiography in patients with acute ankle injuries: role of the physical examination. AJR Am J Roentgenol 1991;157(October (4)):789–91. [2] Stiell IG, Greenberg GH, McKnight RD, Nair RC, McDowell I, Worthington JR. A study to develop clinical decision rules for the use of radiography in acute ankle injuries. Ann Emerg Med 1992;21(April (4)):384–90. [3] Stiell IG, Greenberg GH, McKnight RD, Nair RC, McDowell I, Reardon M, et al. Decision rules for the use of radiography in acute ankle injuries. Refinement and prospective validation. JAMA 1993;269(March (9)):1127–32. [4] Stiell IG, McKnight RD, Greenberg GH, McDowell I, Nair RC, Wells GA, et al. Implementation of the Ottawa ankle rules. JAMA 1994;271:827–32. [5] Schepers T, van Schie-van der Weert EM, de Vries MR, van der Elst M. Foot and ankle fractures at the supination line. Foot (Edinb) 2011;21(September (3)):124–8. [6] Fallat L, Grimm DJ, Saracco JA. Sprained ankle syndrome: prevalence and analysis of 639 acute injuries. J Foot Ankle Surg 1998;37:280–5. [7] Milne CE, Soames RW. The medial collateral ligaments of the human ankle joint: anatomical variations. Foot Ankle Int 1998;19(5):289–92. [8] Campbell KJ, Michalski MP, Wilson KJ, Goldsmith MT, Wijdicks CA, LaPrade RF, et al. The ligament anatomy of the deltoid complex of the ankle: a qualitative and quantitative anatomical study. J Bone Joint Surg Am 2014;16(April):96–8. [9] Judd D, Kim D. Foot fractures frequently misdiagnosed as ankle sprains. Am Fam Physician 2002;66(September (5)):785–95.
Please cite this article in press as: Robinson KP, Davies MB. Talus avulsion fractures: Are they accurately diagnosed? Injury (2015), http://dx.doi.org/10.1016/j.injury.2015.06.041
JINJ-6277; No. of Pages 3 Injury, Int. J. Care Injured xxx (2015) xxx–xxx
Contents lists available at ScienceDirect
Injury journal homepage: www.elsevier.com/locate/injury
Talus avulsion fractures: Are they accurately diagnosed? Karen P. Robinson *, Mark B. Davies Northern General Hospital, Sheffield Teaching Hospitals NHS Trust, Herries Road, Sheffield S5 7AU, United Kingdom
A R T I C L E I N F O
A B S T R A C T
Article history: Accepted 29 June 2015
Dorsal talus avulsion fractures occurring along the supination line of the foot can cause pain and discomfort. Examination of the foot and ankle using the Ottawa ankle rules does not include examination of the talus, an injury here is easily missed causing concern to the patient. This is a retrospective study carried out in a major trauma centre to look at the assessment and diagnosis of all patients with a dorsal talus and navicular avulsion fractures over a one year period. Nineteen patients with an isolated dorsal talus avulsion fracture and five patients with an isolated dorsal navicular fracture were included. The correct diagnosis was made in 12 of patients with isolated dorsal talus avulsion fractures, 7 patients were given an incorrect diagnosis after misreading of the radiograph. Four patients with a dorsal navicular avulsion fracture were given the correct diagnosis. If not correctly diagnosed on presentation patients can be overly concerned that a ‘fracture was missed’ which can lead to confusion and anxiety. Therefore these injuries need to be recognised early, promptly diagnosed, treated symptomatically and reassurance given. We recommend the routine palpation of the talus in addition to the examination set out in the Ottawa Ankle Rules and the close inspection of plain radiographs to adequately diagnose an injury in this area. ß 2015 Elsevier Ltd. All rights reserved.
Keywords: Talus avulsion fracture Ottawa ankle rules Supination line Inversion injuries Ankle sprain
Introduction The supination line of the foot is described as the line dividing the hindfoot and the midfoot. It is the line of rotation that injuries occur along when the foot is forced into supination, or hyper plantarflexion (Fig. 1). There can be bony or ligamentous injury occurring along this line. The dorsal talonavicular ligament and the anterior tibiotalar ligament insert onto the extra articular dorsal surface of the talus (Fig. 2) and when injured can avulse causing a small bony injury (Fig. 3). Dorsal avulsion fractures are considered insignificant [1], but patients presenting with a swollen, bruised and painful foot following an injury are often concerned and seek a diagnosis. The Ottawa Ankle rules were first introduced in 1992 [2]. They were introduced to aid clinicians in their decision making following ankle injuries with an aim of reducing radiography. The rules were validated to be 100% sensitive with a radiography reduction rate of 30–40% [3]. The Ottawa Ankle Rules split the foot and ankle into the malleolar section and the midfoot section by an imaginary line through the talonavicluar joint. Clinicians are encouraged to palpate the distal 6 cm of the fibula and medial
* Corresponding author. Tel.: +44 0114 2434343. E-mail address: [email protected] (K.P. Robinson).
malleolus, the navicular and the base of the 5th metatarsal as these are areas prone to injury with an inversion injury of the ankle [4]. Other areas along the supination line including the talus are not part of the recommended clinical examination according to these rules. The purpose of this study was to address three questions; how common talus avulsion fractures are compared with avulsion fractures of the navicular in our institution? Are talus avulsion fractures adequately identified at presentation? Does the exclusion of talus examination from the OTTAWA ankle rules lead to these fractures being missed? Methods This is a retrospective study carried out in a Major Trauma Centre looking at a one year period. The study was agreed by the local ‘clinical effectiveness unit’. All plain radiographs in our Trust are reported by a radiologist, therefore the radiology database of our hospital was searched using the terms ‘Talus AND Avulsion’, ‘Navicular AND Avulsion’, ‘Talus fracture’ and ‘Navicular fracture’ to identify all patients who had a radiographic diagnosis of an avulsion fracture of the talus, navicular or both between 1st January 2013 and 1st January 2014. The radiographs of all those listed were reviewed to confirm the diagnosis.
http://dx.doi.org/10.1016/j.injury.2015.06.041 0020–1383/ß 2015 Elsevier Ltd. All rights reserved.
Please cite this article in press as: Robinson KP, Davies MB. Talus avulsion fractures: Are they accurately diagnosed? Injury (2015), http://dx.doi.org/10.1016/j.injury.2015.06.041
G Model
JINJ-6277; No. of Pages 3 K.P. Robinson, M.B. Davies / Injury, Int. J. Care Injured xxx (2015) xxx–xxx
2
Fig. 1. Midfoot supination line.
Information detailing; mechanism of injury, weight bearing status on presentation, examination findings, diagnosis made, and subsequent management was collected. Patients involved in major trauma or transferred from another hospital were excluded.
Results Twenty-two patients with an isolated dorsal talus avulsion fracture were identified (Fig. 4). Two patients were excluded from the study, one patient was involved in a major trauma and transferred from another hospital and one patient had an associated distal fibula fracture. Of the remaining 20 patients, 19 sets of notes were available for analysis. Three patients had avulsion fractures of both the dorsal talus and dorsal aspects of the navicular. Two sets of notes were available for analysis. Seven patients had an isolated dorsal navicular avulsion fracture. Five sets of notes were available for analysis. Overall, 15 patients sustained an inversion injury, 6 patients fell downstairs, 2 patients described a simple fall, one tripped in a pot hole, one tripped over a bar on the ground and one had a crush injury. Seven patients were non-weight bearing on presentation, 10 were partially weight bearing and 1 full weight bearing. Thirteen patients had a plain radiograph of the affected ankle, five had a radiograph of the affected foot. The majority of patients presented with pain and swelling of the ankle, with lateral and medial malleolus pain on palpation. In all cases the talus was either not recorded as examined or the ‘midfoot’ was recorded as a single structure. The correct diagnosis was made in 12 patients with isolated dorsal talus avulsion fractures, 7 patients were given an incorrect diagnosis after misreading of the radiograph. Four patients with a dorsal navicular avulsion fracture were given the correct diagnosis. One patient with both a talus and navicular avulsion fracture was misdiagnosed.
Fig. 2. Diagram illustrating the ligaments of the dorsal and medial aspect of the foot.
Of the 7 patients misdiagnosed, 6 were diagnosed with a nonspecific ‘ankle sprain’, with 4 of them documented as no fracture seen. One was diagnosed with a 3rd metatarsal fracture. Two patients represented after the pain and swelling failed to settle, repeat investigations were carried out and the avulsion fracture diagnosed. The remaining patients were recalled to fracture clinic following formal reporting of the radiographs by a Radiologist. All of the patients were partial weight bearing on presentation and 3 of them had swelling but no bony tenderness on palpation.
Fig. 3. Radiograph of avulsion fracture of the talus (white arrow).
Please cite this article in press as: Robinson KP, Davies MB. Talus avulsion fractures: Are they accurately diagnosed? Injury (2015), http://dx.doi.org/10.1016/j.injury.2015.06.041
G Model
JINJ-6277; No. of Pages 3 K.P. Robinson, M.B. Davies / Injury, Int. J. Care Injured xxx (2015) xxx–xxx
3
Fig. 4. Distribution of fracture patterns.
Discussion Supination line fractures of the foot and ankle are easily missed. Schepers et al. [5] reported that dorsal avulsion fractures of the talus account for approximately 1% of all sprains, compared with 2% for navicular fractures. Similarly, Fallat et al. [6] studied 639 patients presenting with ankle sprains, 96 of them involved an osseous injury, 0.5% of these were dorsal talus avulsion fractures and 0.5% were navicular avulsion fractures. In our study, dorsal avulsion fractures were seen more frequently than navicular fractures in a one year period. Sixty three percent of these injuries were correctly diagnosed compared to over 60% misdiagnosis of these injuries reported by Schepers et al. [5]. The dorsal talonavicluar ligament and the anterior tibiotalar ligament are attached to the extra-articular dorsal surface of the talus, but the anterior tibiotalar ligament is poorly described. Milner et al. [7] and Campbell et al. [8] have studied the anatomy of the medial ligaments of the ankle. Both concluded that the tibionavicular, tibiospring and deep posterior tibiotalar ligaments are constant anatomical structures but there is variation in the presence of the deep anterior tibiotalar ligament that inserts into the talus with the dorsal talonavicular ligament. The medial ligament structures are easily injured and it may be the presence of this structure which makes an avulsion fracture of the talus more likely. Talus avulsion fractures are stable injuries that warrant no specific management and are therefore widely considered as insignificant. The supination line is line which runs through the line or articulation of the talus and navicular (Fig. 1). The omission of examination of the talus from the Ottawa Ankle rules can lead to its neglect during examination. Clinicians need a sound anatomical knowledge and routine structured examination of the foot and ankle to ensure an accurate assessment is carried out. Judd [9] comments that talar dome injuries are likely to be diagnosed by following the Ottawa ankle rules due to an inability for the patient to weight bear, but this is not always the case and extra care should be taken when assessing the patient. Extra-articular talus fractures are less of a problem, but patients with a foot injury, resulting in a grossly swollen foot that is not improving are rightly worried. If not correctly diagnosed on presentation they can be overly concerned that a ‘fracture was missed’ which can lead to confusion and anxiety. Therefore these injuries need to be recognised early, promptly diagnosed, treated symptomatically and reassurance given. Further imaging in these injuries is rarely required, a CT scan may be appropriate if there is suspicion of a bigger injury to the foot, presenting as a large clinically bruised and swollen foot out of
proportion to radiographic findings or if plain radiographs suggests midfoot instability. Fallat et al. [6] suggest that defining these often complex injuries as an ankle sprain syndrome would help clinical assessment and accuracy by encouraging a more thorough examination. Conclusion The Ottawa ankle rules are a sound clinical recommendation and an aid to identify the need for plain radiographs of the foot and ankle after trauma. Clinicians need to develop a secure anatomical knowledge of the foot and ankle and a routine structured examination to include palpation of the talus in conjunction with the principles set out in the Ottawa ankle rules. Close inspection of plain radiographs, if requested, is necessary to adequately diagnose an injury around the supination line. Conflict of interest The authors have no conflicts of interest to declare. Acknowledgements Foot and ankle illustration (Figs. 1 and 2) by Mr. Grant Lynas. References [1] Auletta AG, Conway WF, Hayes CW, Guisto DF, Gervin AS. Indications for radiography in patients with acute ankle injuries: role of the physical examination. AJR Am J Roentgenol 1991;157(October (4)):789–91. [2] Stiell IG, Greenberg GH, McKnight RD, Nair RC, McDowell I, Worthington JR. A study to develop clinical decision rules for the use of radiography in acute ankle injuries. Ann Emerg Med 1992;21(April (4)):384–90. [3] Stiell IG, Greenberg GH, McKnight RD, Nair RC, McDowell I, Reardon M, et al. Decision rules for the use of radiography in acute ankle injuries. Refinement and prospective validation. JAMA 1993;269(March (9)):1127–32. [4] Stiell IG, McKnight RD, Greenberg GH, McDowell I, Nair RC, Wells GA, et al. Implementation of the Ottawa ankle rules. JAMA 1994;271:827–32. [5] Schepers T, van Schie-van der Weert EM, de Vries MR, van der Elst M. Foot and ankle fractures at the supination line. Foot (Edinb) 2011;21(September (3)):124–8. [6] Fallat L, Grimm DJ, Saracco JA. Sprained ankle syndrome: prevalence and analysis of 639 acute injuries. J Foot Ankle Surg 1998;37:280–5. [7] Milne CE, Soames RW. The medial collateral ligaments of the human ankle joint: anatomical variations. Foot Ankle Int 1998;19(5):289–92. [8] Campbell KJ, Michalski MP, Wilson KJ, Goldsmith MT, Wijdicks CA, LaPrade RF, et al. The ligament anatomy of the deltoid complex of the ankle: a qualitative and quantitative anatomical study. J Bone Joint Surg Am 2014;16(April):96–8. [9] Judd D, Kim D. Foot fractures frequently misdiagnosed as ankle sprains. Am Fam Physician 2002;66(September (5)):785–95.
Please cite this article in press as: Robinson KP, Davies MB. Talus avulsion fractures: Are they accurately diagnosed? Injury (2015), http://dx.doi.org/10.1016/j.injury.2015.06.041