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Transcalcaneal Talonavicular Dislocation Associated with an Open Comminuted Calcaneal Fracture: A Case Report
Tra n s c a l c a n e a l Ta l o n a v i c u l a r Dislocation Associated with an Open Comminuted C a l c a n e a l F r a c t u re: A Case Report Spyridon P. Galanakos, Ioannis P. Sofianos, MD
MD, PhD*,
Vassilios Papathanasiou,
MD,
KEYWORDS Foot Trauma Dislocation Open fracture Talus Calcaneus
The combination of dorsal dislocation of the navicular from the talus and a comminuted fracture of the calcaneus (transcalcaneal talonavicular dislocation) is an unusual and severe injury.1–3 It occurs due to a forced plantarflexion of the talar head through the anterior portion of the calcaneum and is usually associated with a potential for skin and neurovascular compromise. To the authors’ knowledge, few cases have been reported previously in the literature.1,3–5 This article reports an unusual case of an open transcalcaneal talonavicular dislocation associated with the presence of a calcaneal comminuted calcaneal fracture. CASE REPORT
A 27-year-old healthy man, a manual worker, injured his left hindfoot after a fall from height while at work. After assessment in an accident and emergency department, he was found to have a deformity of his hindfoot and a wound measuring approximately 15 cm long extended from the medial malleolus to the plantar aspect of his heel with small bone fragments exposed in the wound. There was no neurovascular compromise in his injured left foot. Clinical photographs of the wound were taken, the wound Conflict of interest: None of the authors of this manuscript has financial or personal relationships that could inappropriately influence the authors’ decisions, work, or manuscript. Department of Orthopaedics, General Hospital of Levadia, Levadia, Greece * Corresponding author. 14-16 Trikalon Street, 11526, Ambelokipi, Athens, Greece. E-mail address: [email protected] Clin Podiatr Med Surg 28 (2011) 763–767 doi:10.1016/j.cpm.2011.07.002 podiatric.theclinics.com 0891-8422/11/$ – see front matter Ó 2011 Elsevier Inc. All rights reserved.
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Fig. 1. Intraoperative appearance of the open calcaneal fracture (A, B) and lateral radiograph of the left foot and ankle showing the transcalcaneal talonavicular dislocation with an associated comminuted calcaneal fracture (C).
was covered with sterile dressing, adequate tetanus and antibiotic prophylaxis were administrated, and the foot was secured with a posterior fiberglass splint dressing (Fig. 1A, B). Anteroposterior, lateral, and oblique radiographs of the foot and ankle were obtained and revealed a multifragmentary fracture of the calcaneum associated with a talonavicular dislocation. The talus was planterflexed with its head portion displaced plantarwards through the calcaneal fracture (see Fig. 1C). The radiologic findings revealed no other associated fractures. The patient was brought to the operating room on an urgent basis and after induction of general anesthesia and sterile prepping, the wound was adequately excised to healthy margins and irrigated with at least 10 L of normal saline solution while the foot dislocation was reduced under C-arm fluoroscopy. The talonavicular joint was stabilized with 2-mm Kirschner wires (K-wires) introduced from the dorsal and medial aspect of the foot transfixing the talonavicular joint. Furthermore, the calcaneal fracture was manipulated through the open wound to obtain better alignment and using a hybrid Ace-Fisher External Fixation System (DePuy Ace, Warsaw, IN, USA). The reduction of the dislocation was achieved with satisfactory results and the foot and ankle were stabilized with the external fixation system. The traumatic wound was also closed primarily (Fig. 2).
Fig. 2. Postoperative lateral radiograph after reduction and external fixator placement.
Transcalcaneal Talonavicular Dislocation
Intravenous antibiotics were continued 72 hours after the surgery and low molecular weight heparin prophylaxis was administered during the hospital course. Five days after the procedure, a minor surgical wound edge necrosis with superficial infection was developed and successfully treated with multiple operative irrigations, de´bridements, and oral antibiotics (Fig. 3A). The patient was discharged from the hospital on the twelfth postoperative day. Three weeks later, the wound was healed completely without any further complications and after that it was managed with normal dry sterile dressing changes (see Fig. 3B). At 6 weeks postoperatively, the K-wires from the talonavicular joint were removed, but the hybrid fixator remained for an additional 10 weeks. The patient was to remain non–weight bearing for approximately 16 weeks. After the external fixator removal, the patient was allowed to maintain a weight-bearing status as tolerated with assistance of crutches. At the 8-month follow-up, he was able to walk with full weight bearing independently and the patient returned to his occupation as a clerk. At the end of the first postoperative year, range of motion of his left ankle was dorsiflexion 5 , plantarflexion 40 , inversion 20 , and eversion 10 . Radiographs at that time showed mild degenerative changes at the talotibial joint and some degree of space narrowing at talotibial, talonavicular, and subtalar joints (Fig. 4). The American Orthopaedic Foot and Ankle Society hindfoot score6 at 18 months was 63. After 2 years of the injury, the patient was lost to follow-up. No clinical or radiologic signs of osteomyelitis or avascular necrosis were developed until the last assessment. DISCUSSION
Association of dorsal dislocation of the navicular from the talus with an open fracture of the calcaneus is an uncommon but severe injury. Coltart in 19521 was the first to report such injuries; he described 5 cases of severe comminution of the calcaneum with fracture through the neck of the talus with the body of the talus inverted and embedded in the calcaneum. He impressed that these injuries were severe and usually open and often became infected. Three of the 5 patients required a below-the-knee amputation. Kleiger3 schematically described a similar type of injury with plantar dislocation of the talus at the talonavicular joint and calcaneal fracture as one of the mechanisms of talar injury. In 1993, Ebraheim and colleagues2 reported two cases of complex fracture-dislocation of the calcaneus. A different mechanism of injury, from that in our study, was described, where the talus was dislocated and plantarflexed and the calcaneus was dislocated laterally with a highly comminuted fracture.
Fig. 3. A minor surgical wound edge necrosis with superficial infection was noted 5 days postoperatively (A) and clinical appearance of the foot and ankle with the apparatus at the fifth postoperative week (B).
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Fig. 4. Final radiograph (A) and clinical appearance of the left foot and ankle (B, C) at the end of the first postoperative year.
In addition, Ricci and colleagues4 reported a detailed description of the transcalcaneal talonavicular dislocation and its variations in injury pattern with methods and treatment options. There were 9 cases of transcalcaneal talonavicular dislocation of which 5 were open injuries. Four of these developed osteomyelitis and 3 subsequently required amputation. Open fractures of the calcaneum are rare injuries, representing between 0.8% and 10% of all os calcis fractures in published series.7,8 Open calcaneal fractures are characterized by an increased frequency of infection despite the strict protocols of treating these complex open injuries. Associated complications may include but are not limited to sympathetic algodystrophy, subtalar arthritis, calcaneocuboid arthritis, malunion, tendinitis of fibularis, and remaining ankle pain.9,10 No other major complications were noted in the authors’ case patient. It is known that the goals of open calcaneal fracture management include timely healing of the soft tissue without infection and maintenance of bony alignment.11 Some investigators recommended that management of the soft tissue disruption and avoidance of infection should be the initial treatment focus rather than fracture stabilization.10,12 The stability provided by early internal fixation of open fractures is believed, however, to diminish the risk of infection and promote healing of the injured soft tissues.13,14 The characteristic of the authors’ case patient’s injury pattern was plantar dislocation of the talus from the navicular associated with a severely comminuted open calcaneal fracture. A remarkable functional outcome was achieved with one major surgical procedure, and only local further de´bridements were necessary due to minor wound problems. Although general treatment recommendation for severely intra-articular fractures of the posterior facet is early or late subtalar arthrodesis,11 immediate minimally invasive fixation with percutaneous pinning and external fixation needs to be considered for the healthy and active patients. It is usually not possible to restore all parts of a comminuted calcaneal fracture with an external fixator, but the aim of the apparatus in the presented case was to provide further stabilization and better alignment of the calcaneus. In the authors’ case report, the patient was able to walk with full weight bearing and without any assistance at the eighth postoperative month and he was pleased with the outcome. Posttraumatic arthritis, however, is usually a late phenomenon with these types of injuries and may need to be addressed if a patient becomes symptomatic in the future. The authors’ percutaneous fixation technique was used to eliminate the option of a primary arthrodesis at the time of his severe open injury and significant amount of soft tissue loss. SUMMARY
This article presents a case report of a plantar dislocation of the talus from the navicular associated with a severely comminuted open calcaneal fracture, managed by one
Transcalcaneal Talonavicular Dislocation
surgical procedure and a good clinical outcome. Besides the good results of the case patient, the prognosis for most of these types of injuries varies from severe functional limitations and/or chronic pain to even amputation. REFERENCES
1. Coltart WD. Aviator’s astragalus. J Bone Joint Surg Br 1952;34:545–66. 2. Ebraheim NA, Savolaine ER, Paley K, et al. Comminuted fracture of the calcaneus associated with subluxation of the talus. Foot Ankle 1993;14:380–4. 3. Kleiger B. Injuries of the talus and its joints. Clin Orthop Relat Res 1976;121: 243–62. 4. Ricci WM, Bellabarba C, Sanders R. Transcalcaneal talonavicular dislocation. J Bone Joint Surg Am 2002;84:557–61. 5. Kamath RP, Chandran P, Nihal A. Transcalcaneal talonavicular dislocation. Foot Ankle Surg 2007;13:147–9. 6. Kitaoka HB, Alexander IJ, Adelaar RS, et al. Clinical rating systems for the ankle—hindfoot, midfoot, hallux and lesser toes. Foot Ankle Int 1994;15:349–53. 7. Benirschke SK, Sangeorzan BJ. Extensive intra-articular fractures of the foot. Clin Orthop Relat Res 1993;292:128–34. 8. Soeur R, Remy R. Fractures of the calcaneus with displacement of the thalamic portion. J Bone Joint Surg Br 1975;57:413–21. 9. Berry GK, Stevens DG, Kreder HJ, et al. Open fractures of the calcaneus. A review of treatment and outcome. J Orthop Trauma 2004;18:202–6. 10. Siebert CH, Hansen M, Wolter D. Follow-up evaluation of open intra-articular fractures of the calcaneus. Arch Orthop Trauma Surg 1998;117:442–7. 11. Lawrence SJ. Open calcaneal fractures. Orthopedics 2004;27(7):737–42. 12. Aldridge JM III, Easley M, Nunley JA. Open calcaneal fractures. J Orthop Trauma 2004;18:7–11. 13. Chapman MW, Mahoney M. The role of early internal fixation in the management of open fractures. Clin Orthop Relat Res 1979;138:120–31. 14. Franklin JL, Johnson KD, Hansen ST. Immediate internal fixation of open ankle fractures. Report of 38 cases treated with a standard protocol. J Bone Joint Surg Am 1984;66:1349–56.
767
MD, PhD*,
Vassilios Papathanasiou,
MD,
KEYWORDS Foot Trauma Dislocation Open fracture Talus Calcaneus
The combination of dorsal dislocation of the navicular from the talus and a comminuted fracture of the calcaneus (transcalcaneal talonavicular dislocation) is an unusual and severe injury.1–3 It occurs due to a forced plantarflexion of the talar head through the anterior portion of the calcaneum and is usually associated with a potential for skin and neurovascular compromise. To the authors’ knowledge, few cases have been reported previously in the literature.1,3–5 This article reports an unusual case of an open transcalcaneal talonavicular dislocation associated with the presence of a calcaneal comminuted calcaneal fracture. CASE REPORT
A 27-year-old healthy man, a manual worker, injured his left hindfoot after a fall from height while at work. After assessment in an accident and emergency department, he was found to have a deformity of his hindfoot and a wound measuring approximately 15 cm long extended from the medial malleolus to the plantar aspect of his heel with small bone fragments exposed in the wound. There was no neurovascular compromise in his injured left foot. Clinical photographs of the wound were taken, the wound Conflict of interest: None of the authors of this manuscript has financial or personal relationships that could inappropriately influence the authors’ decisions, work, or manuscript. Department of Orthopaedics, General Hospital of Levadia, Levadia, Greece * Corresponding author. 14-16 Trikalon Street, 11526, Ambelokipi, Athens, Greece. E-mail address: [email protected] Clin Podiatr Med Surg 28 (2011) 763–767 doi:10.1016/j.cpm.2011.07.002 podiatric.theclinics.com 0891-8422/11/$ – see front matter Ó 2011 Elsevier Inc. All rights reserved.
764
Galanakos et al
Fig. 1. Intraoperative appearance of the open calcaneal fracture (A, B) and lateral radiograph of the left foot and ankle showing the transcalcaneal talonavicular dislocation with an associated comminuted calcaneal fracture (C).
was covered with sterile dressing, adequate tetanus and antibiotic prophylaxis were administrated, and the foot was secured with a posterior fiberglass splint dressing (Fig. 1A, B). Anteroposterior, lateral, and oblique radiographs of the foot and ankle were obtained and revealed a multifragmentary fracture of the calcaneum associated with a talonavicular dislocation. The talus was planterflexed with its head portion displaced plantarwards through the calcaneal fracture (see Fig. 1C). The radiologic findings revealed no other associated fractures. The patient was brought to the operating room on an urgent basis and after induction of general anesthesia and sterile prepping, the wound was adequately excised to healthy margins and irrigated with at least 10 L of normal saline solution while the foot dislocation was reduced under C-arm fluoroscopy. The talonavicular joint was stabilized with 2-mm Kirschner wires (K-wires) introduced from the dorsal and medial aspect of the foot transfixing the talonavicular joint. Furthermore, the calcaneal fracture was manipulated through the open wound to obtain better alignment and using a hybrid Ace-Fisher External Fixation System (DePuy Ace, Warsaw, IN, USA). The reduction of the dislocation was achieved with satisfactory results and the foot and ankle were stabilized with the external fixation system. The traumatic wound was also closed primarily (Fig. 2).
Fig. 2. Postoperative lateral radiograph after reduction and external fixator placement.
Transcalcaneal Talonavicular Dislocation
Intravenous antibiotics were continued 72 hours after the surgery and low molecular weight heparin prophylaxis was administered during the hospital course. Five days after the procedure, a minor surgical wound edge necrosis with superficial infection was developed and successfully treated with multiple operative irrigations, de´bridements, and oral antibiotics (Fig. 3A). The patient was discharged from the hospital on the twelfth postoperative day. Three weeks later, the wound was healed completely without any further complications and after that it was managed with normal dry sterile dressing changes (see Fig. 3B). At 6 weeks postoperatively, the K-wires from the talonavicular joint were removed, but the hybrid fixator remained for an additional 10 weeks. The patient was to remain non–weight bearing for approximately 16 weeks. After the external fixator removal, the patient was allowed to maintain a weight-bearing status as tolerated with assistance of crutches. At the 8-month follow-up, he was able to walk with full weight bearing independently and the patient returned to his occupation as a clerk. At the end of the first postoperative year, range of motion of his left ankle was dorsiflexion 5 , plantarflexion 40 , inversion 20 , and eversion 10 . Radiographs at that time showed mild degenerative changes at the talotibial joint and some degree of space narrowing at talotibial, talonavicular, and subtalar joints (Fig. 4). The American Orthopaedic Foot and Ankle Society hindfoot score6 at 18 months was 63. After 2 years of the injury, the patient was lost to follow-up. No clinical or radiologic signs of osteomyelitis or avascular necrosis were developed until the last assessment. DISCUSSION
Association of dorsal dislocation of the navicular from the talus with an open fracture of the calcaneus is an uncommon but severe injury. Coltart in 19521 was the first to report such injuries; he described 5 cases of severe comminution of the calcaneum with fracture through the neck of the talus with the body of the talus inverted and embedded in the calcaneum. He impressed that these injuries were severe and usually open and often became infected. Three of the 5 patients required a below-the-knee amputation. Kleiger3 schematically described a similar type of injury with plantar dislocation of the talus at the talonavicular joint and calcaneal fracture as one of the mechanisms of talar injury. In 1993, Ebraheim and colleagues2 reported two cases of complex fracture-dislocation of the calcaneus. A different mechanism of injury, from that in our study, was described, where the talus was dislocated and plantarflexed and the calcaneus was dislocated laterally with a highly comminuted fracture.
Fig. 3. A minor surgical wound edge necrosis with superficial infection was noted 5 days postoperatively (A) and clinical appearance of the foot and ankle with the apparatus at the fifth postoperative week (B).
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Fig. 4. Final radiograph (A) and clinical appearance of the left foot and ankle (B, C) at the end of the first postoperative year.
In addition, Ricci and colleagues4 reported a detailed description of the transcalcaneal talonavicular dislocation and its variations in injury pattern with methods and treatment options. There were 9 cases of transcalcaneal talonavicular dislocation of which 5 were open injuries. Four of these developed osteomyelitis and 3 subsequently required amputation. Open fractures of the calcaneum are rare injuries, representing between 0.8% and 10% of all os calcis fractures in published series.7,8 Open calcaneal fractures are characterized by an increased frequency of infection despite the strict protocols of treating these complex open injuries. Associated complications may include but are not limited to sympathetic algodystrophy, subtalar arthritis, calcaneocuboid arthritis, malunion, tendinitis of fibularis, and remaining ankle pain.9,10 No other major complications were noted in the authors’ case patient. It is known that the goals of open calcaneal fracture management include timely healing of the soft tissue without infection and maintenance of bony alignment.11 Some investigators recommended that management of the soft tissue disruption and avoidance of infection should be the initial treatment focus rather than fracture stabilization.10,12 The stability provided by early internal fixation of open fractures is believed, however, to diminish the risk of infection and promote healing of the injured soft tissues.13,14 The characteristic of the authors’ case patient’s injury pattern was plantar dislocation of the talus from the navicular associated with a severely comminuted open calcaneal fracture. A remarkable functional outcome was achieved with one major surgical procedure, and only local further de´bridements were necessary due to minor wound problems. Although general treatment recommendation for severely intra-articular fractures of the posterior facet is early or late subtalar arthrodesis,11 immediate minimally invasive fixation with percutaneous pinning and external fixation needs to be considered for the healthy and active patients. It is usually not possible to restore all parts of a comminuted calcaneal fracture with an external fixator, but the aim of the apparatus in the presented case was to provide further stabilization and better alignment of the calcaneus. In the authors’ case report, the patient was able to walk with full weight bearing and without any assistance at the eighth postoperative month and he was pleased with the outcome. Posttraumatic arthritis, however, is usually a late phenomenon with these types of injuries and may need to be addressed if a patient becomes symptomatic in the future. The authors’ percutaneous fixation technique was used to eliminate the option of a primary arthrodesis at the time of his severe open injury and significant amount of soft tissue loss. SUMMARY
This article presents a case report of a plantar dislocation of the talus from the navicular associated with a severely comminuted open calcaneal fracture, managed by one
Transcalcaneal Talonavicular Dislocation
surgical procedure and a good clinical outcome. Besides the good results of the case patient, the prognosis for most of these types of injuries varies from severe functional limitations and/or chronic pain to even amputation. REFERENCES
1. Coltart WD. Aviator’s astragalus. J Bone Joint Surg Br 1952;34:545–66. 2. Ebraheim NA, Savolaine ER, Paley K, et al. Comminuted fracture of the calcaneus associated with subluxation of the talus. Foot Ankle 1993;14:380–4. 3. Kleiger B. Injuries of the talus and its joints. Clin Orthop Relat Res 1976;121: 243–62. 4. Ricci WM, Bellabarba C, Sanders R. Transcalcaneal talonavicular dislocation. J Bone Joint Surg Am 2002;84:557–61. 5. Kamath RP, Chandran P, Nihal A. Transcalcaneal talonavicular dislocation. Foot Ankle Surg 2007;13:147–9. 6. Kitaoka HB, Alexander IJ, Adelaar RS, et al. Clinical rating systems for the ankle—hindfoot, midfoot, hallux and lesser toes. Foot Ankle Int 1994;15:349–53. 7. Benirschke SK, Sangeorzan BJ. Extensive intra-articular fractures of the foot. Clin Orthop Relat Res 1993;292:128–34. 8. Soeur R, Remy R. Fractures of the calcaneus with displacement of the thalamic portion. J Bone Joint Surg Br 1975;57:413–21. 9. Berry GK, Stevens DG, Kreder HJ, et al. Open fractures of the calcaneus. A review of treatment and outcome. J Orthop Trauma 2004;18:202–6. 10. Siebert CH, Hansen M, Wolter D. Follow-up evaluation of open intra-articular fractures of the calcaneus. Arch Orthop Trauma Surg 1998;117:442–7. 11. Lawrence SJ. Open calcaneal fractures. Orthopedics 2004;27(7):737–42. 12. Aldridge JM III, Easley M, Nunley JA. Open calcaneal fractures. J Orthop Trauma 2004;18:7–11. 13. Chapman MW, Mahoney M. The role of early internal fixation in the management of open fractures. Clin Orthop Relat Res 1979;138:120–31. 14. Franklin JL, Johnson KD, Hansen ST. Immediate internal fixation of open ankle fractures. Report of 38 cases treated with a standard protocol. J Bone Joint Surg Am 1984;66:1349–56.
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