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Unusual ankle injury—a case report
The Foot 14 (2004) 169–172
Case report
Unusual ankle injury—a case report K. Shah a,∗ , A. Hakmi b,1 a b
SpR, T&O, St. Mary’s Hospital, London W2 1NY, UK SpR, T&O, Royal Hospital, Chesterfield S44 5BL, UK
Abstract A 45-year-old lady had sustained an open injury to her right ankle after an inversion injury. A clinical diagnosis of fracture dislocation of the ankle was made, and the patient was taken to theatre for internal fixation of the oblique fracture of the medial malleolus. However, on table in the operating theatre, under the image intensifier, the patient was also found to have a fracture of the talus, which was hitherto unknown. Discussion: Traumatizing forces to the talus are transmitted via the adjacent structures, of which the deltoid ligament is very important, as an intact deltoid protects the body of the talus against shear forces from the distal tibia. Fractures of the body of talus involve appreciable disability, hence, routine examination of ankle injuries should also address the talus, apart from the fibula and the fifth metatarsal, in order to avoid potentially devastating complications. We believe that some of the “ankle sprains” that we come across so often, may have subtle injuries to the talus, and we need to make all efforts to diagnose it as early as possible to counsel the patient regarding their poor prognosis. © 2004 Elsevier Ltd. All rights reserved. Keywords: Fracture; Talus; Ankle; X-rays; Internal fixation
1. Case A 45-year-old lady, who presented to the A&E department, had sustained an open injury to her right ankle, after an inversion injury. When examined, she had an obvious deformity of her ankle, with her foot lying supinated and adducted, and a laceration of about 5 cm over the lateral malleolus. There was no skin or soft tissue loss. The casualty officer had made a note that the fibula was protruding from the wound. She had a well-palpable dorsalis pedis pulse and an intact sensation all over her foot. A clinical diagnosis of fracture dislocation of the ankle was made, and the dislocation was successfully reduced under sedation and antibiotic cover in A&E. A below-knee back-slab was applied, and AP and lateral radiographs were taken (Fig. 1a and b). They revealed an oblique fracture of the medial malleolus. The ankle mortice was well reduced. The patient was admitted on an orthopaedic ward, and taken to theatre 5 h after the injury, for debridement of the lateral wound and internal fixation of the medial malleolus.
∗ Corresponding author. Tel.: +44-207-886-6666x1061; fax: +44-207-886-1471. E-mail address: [email protected] (K. Shah). 1 Tel.: +44-1246-277271x367; fax: +44-1246-552660.
0958-2592/$ – see front matter © 2004 Elsevier Ltd. All rights reserved. doi:10.1016/j.foot.2004.03.005
On the table in theatre, after cleaning the wound thoroughly, the medial malleolus fracture was reduced by closed means, and the reduction was checked under the image intensifier. The image films (Fig. 2a and b) revealed a fracture through the body of talus as well, which was hitherto unknown. The fracture line was oblique, in the coronal plane of the body of talus, splitting it into essentially two parts. We reviewed the pre-operative X-rays (taken in A&E) to look for the fracture line, but we could not see any. The image films were printed for record, and the talus fracture was fixed with two cancellous screws from the lateral side. The medial malleolus too was fixed with two cancellous screws through a stab incision on the medial side. Post-operative image films and proper check-X-rays were satisfactory (Fig. 3). The patient’s wound was inspected after 48 h, and a below knee cast applied. She was subsequently discharged with oral antibiotics.
2. Discussion Fracture of the body of talus is a very unusual injury, and one in combination with fracture of the medial malleolus is extremely rare. We could not find any reports in literature of mention of a similar combination. Generally, the talus is well protected from direct outer forces, and the traumatizing
170
K. Shah, A. Hakmi / The Foot 14 (2004) 169–172
Fig. 1. AP and lateral radiograph of the ankle showing oblique fracture of the medial malleolus, with the ankle mortice well reduced.
forces are transmitted mainly via the adjacent structures, of which the deltoid ligament is very important, as an intact deltoid exerts a restraining influence on external rotation of the talus [1]. Sneppen and Buhl [2] found that forces that act upon the talus and produce fracture of this bone affects also the ankle joint, which occasionally is fractured at the same time. Thus, fracture of the talus is not an isolated phenomenon, but a link in a more comprehensive injury involving the ankle joint. Fractures of the body of talus have been classified into: (1) (2) (3) (4) (5)
Compression injuries Shear fracture Fracture of the posterior process Fracture of the lateral process Crush fracture
Sneppen and Buhl (1974) [2] also found that only certain non-physical forces, e.g., pronounced caudal compression, pronation, and, especially supination trauma, would injure the body of talus. They found that a medial site fracture was typical of the supination trauma (compression or shear type), whereas a lateral site was typical of pronation or pronation-external rotation trauma (compression fracture).
The other common mechanism of injury resulting in fracture of the body of talus is a fall from a height, producing an axial compression of the talus between the tibial plafond and the calcaneus. In cases of simultaneous ankle and talus fracture, the pathological movement of the foot at the moment of the accident can be known and related to the morphology of the talus fracture [2]. Our case, with an adducted foot at the time of presentation, most likely had a supination trauma, which produced an oblique fracture of the medial malleolus. Without the protection from the medial side, the body of talus was exposed to shearing forces against the distal tibia, producing an oblique shear fracture of the body of the talus. The shear fracture can be a coronal shear or a sagittal shear. In most instances of talar body fracture, there is significant displacement of the fragments with concurrent subluxation of the ankle or subtalar joints. In our case it was difficult to ascertain the initial displacement of the body of talus as there were no films showing the initial displacement, but it is possible that the talus was protruding from the wound and was mistaken as the lower end of fibula. Owing to its central functions, fractures of the talar body often involve appreciable disability, and this is further accen-
K. Shah, A. Hakmi / The Foot 14 (2004) 169–172
Fig. 2. On-table AP and lateral films of the ankle—fracture of the body of the talus, splitting it into two parts.
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K. Shah, A. Hakmi / The Foot 14 (2004) 169–172
Fig. 3. Post-operative AP and lateral films showing the internal fixation of the fracture of the talus and the medial malleolus.
tuated by the special vascularization conditions which arise in certain regional injuries, involving a marked risk of avascular necrosis of the body. Both osteonecrosis and arthritis of the ankle and subtalar joints occur often, resulting in disabling pain because of the critical function of these articulations in gait (Sneppen and Buhl, 1974) [2]. Late results are characterized by appreciable subjective complaints and rehabilitation difficulties. Outcomes vary widely and are related to the degree of initial fracture displacement. Failure to recognize fracture displacement (even when minimal) can lead to under treatment and poor outcomes [3]. Sneppen et al. [4], who have done the best review of 31 patients, have recommended ‘exact reduction and stable fixation wherever possible.’ Even after restoration of congruity
of adjacent joints, early complications are not infrequent and most patients have development of radiographic evidence of osteonecrosis and/or post-traumatic arthritis [5]. These complications are worse after open fractures [5]. Interestingly, medial malleolar osteotomy is recommended for better exposure of the body of talus (in our case, patient had a fracture of the medial malleolus). Osteonecrosis may be less likely to occur when fracture of the talus is accompanied by a fracture of the malleoli, which preserves the soft-tissue attachments to the talar-body fragments. Overall we are reporting an unusual combination of fracture dislocation of talus with fracture of medial malleolus, which is hitherto, unreported. The mechanism of injury was fairly common, and the fracture of talus could have been missed, leading to potentially disastrous consequences. We hope this will help us to remind ourselves that fracture of talus can be a part of a ‘common’ ankle injury, and clinical examination of ankle injuries should also address the talus, apart from the fibula and the fifth metatarsal [6]. We believe that some of the “ankle sprains” that we come across so often, may have subtle injuries to the talus. Because fracture of the body of talus has a high incidence of complications, we need to make all efforts to diagnose it as early as possible and counsel the patient regarding these devastating injuries and their poor prognosis and potential complications. The long-term outcome of this patient is still awaited.
References [1] J.D. Michelsen, U.M. Ahn, S.L. Helgemo, Motion of the ankle in a simulated supination-external rotation fracture model, J. Bone Joint Surg. Am. 78 (7) (1996) 1024–1031. [2] O. Sneppen, O. Buhl, Fracture of the Talus-A study of its genesis and morphology based upon cases with associated ankle fracture, Acta Orthop. Scand. 45 (1974) 307–320. [3] P.T. Fortin, J.E. Balazsy, Talus fracture: evaluation and treatment, J. Am. Acad. Orthop. Surg. 9 (2) (2001) 114–127. [4] O. Sneppen, S.B. Christensen, O. Krosgoe, J. Lorentzes, Fracture of the body of the Talus, Acta Orthop. Scand. 48 (1977) 317–324. [5] H.A. Vallier, S.E. Nork, S.K. Benirschke, Surgical treatment of talar body fractures, J. Bone Joint Surg. Am. 85-A (9) (2003) 1716–1724. [6] G. Mollenhoff, J. Richter, G. Muhr, Supination trauma. A classic case, Orthopade 28 (6) (1999) 469–475.
Case report
Unusual ankle injury—a case report K. Shah a,∗ , A. Hakmi b,1 a b
SpR, T&O, St. Mary’s Hospital, London W2 1NY, UK SpR, T&O, Royal Hospital, Chesterfield S44 5BL, UK
Abstract A 45-year-old lady had sustained an open injury to her right ankle after an inversion injury. A clinical diagnosis of fracture dislocation of the ankle was made, and the patient was taken to theatre for internal fixation of the oblique fracture of the medial malleolus. However, on table in the operating theatre, under the image intensifier, the patient was also found to have a fracture of the talus, which was hitherto unknown. Discussion: Traumatizing forces to the talus are transmitted via the adjacent structures, of which the deltoid ligament is very important, as an intact deltoid protects the body of the talus against shear forces from the distal tibia. Fractures of the body of talus involve appreciable disability, hence, routine examination of ankle injuries should also address the talus, apart from the fibula and the fifth metatarsal, in order to avoid potentially devastating complications. We believe that some of the “ankle sprains” that we come across so often, may have subtle injuries to the talus, and we need to make all efforts to diagnose it as early as possible to counsel the patient regarding their poor prognosis. © 2004 Elsevier Ltd. All rights reserved. Keywords: Fracture; Talus; Ankle; X-rays; Internal fixation
1. Case A 45-year-old lady, who presented to the A&E department, had sustained an open injury to her right ankle, after an inversion injury. When examined, she had an obvious deformity of her ankle, with her foot lying supinated and adducted, and a laceration of about 5 cm over the lateral malleolus. There was no skin or soft tissue loss. The casualty officer had made a note that the fibula was protruding from the wound. She had a well-palpable dorsalis pedis pulse and an intact sensation all over her foot. A clinical diagnosis of fracture dislocation of the ankle was made, and the dislocation was successfully reduced under sedation and antibiotic cover in A&E. A below-knee back-slab was applied, and AP and lateral radiographs were taken (Fig. 1a and b). They revealed an oblique fracture of the medial malleolus. The ankle mortice was well reduced. The patient was admitted on an orthopaedic ward, and taken to theatre 5 h after the injury, for debridement of the lateral wound and internal fixation of the medial malleolus.
∗ Corresponding author. Tel.: +44-207-886-6666x1061; fax: +44-207-886-1471. E-mail address: [email protected] (K. Shah). 1 Tel.: +44-1246-277271x367; fax: +44-1246-552660.
0958-2592/$ – see front matter © 2004 Elsevier Ltd. All rights reserved. doi:10.1016/j.foot.2004.03.005
On the table in theatre, after cleaning the wound thoroughly, the medial malleolus fracture was reduced by closed means, and the reduction was checked under the image intensifier. The image films (Fig. 2a and b) revealed a fracture through the body of talus as well, which was hitherto unknown. The fracture line was oblique, in the coronal plane of the body of talus, splitting it into essentially two parts. We reviewed the pre-operative X-rays (taken in A&E) to look for the fracture line, but we could not see any. The image films were printed for record, and the talus fracture was fixed with two cancellous screws from the lateral side. The medial malleolus too was fixed with two cancellous screws through a stab incision on the medial side. Post-operative image films and proper check-X-rays were satisfactory (Fig. 3). The patient’s wound was inspected after 48 h, and a below knee cast applied. She was subsequently discharged with oral antibiotics.
2. Discussion Fracture of the body of talus is a very unusual injury, and one in combination with fracture of the medial malleolus is extremely rare. We could not find any reports in literature of mention of a similar combination. Generally, the talus is well protected from direct outer forces, and the traumatizing
170
K. Shah, A. Hakmi / The Foot 14 (2004) 169–172
Fig. 1. AP and lateral radiograph of the ankle showing oblique fracture of the medial malleolus, with the ankle mortice well reduced.
forces are transmitted mainly via the adjacent structures, of which the deltoid ligament is very important, as an intact deltoid exerts a restraining influence on external rotation of the talus [1]. Sneppen and Buhl [2] found that forces that act upon the talus and produce fracture of this bone affects also the ankle joint, which occasionally is fractured at the same time. Thus, fracture of the talus is not an isolated phenomenon, but a link in a more comprehensive injury involving the ankle joint. Fractures of the body of talus have been classified into: (1) (2) (3) (4) (5)
Compression injuries Shear fracture Fracture of the posterior process Fracture of the lateral process Crush fracture
Sneppen and Buhl (1974) [2] also found that only certain non-physical forces, e.g., pronounced caudal compression, pronation, and, especially supination trauma, would injure the body of talus. They found that a medial site fracture was typical of the supination trauma (compression or shear type), whereas a lateral site was typical of pronation or pronation-external rotation trauma (compression fracture).
The other common mechanism of injury resulting in fracture of the body of talus is a fall from a height, producing an axial compression of the talus between the tibial plafond and the calcaneus. In cases of simultaneous ankle and talus fracture, the pathological movement of the foot at the moment of the accident can be known and related to the morphology of the talus fracture [2]. Our case, with an adducted foot at the time of presentation, most likely had a supination trauma, which produced an oblique fracture of the medial malleolus. Without the protection from the medial side, the body of talus was exposed to shearing forces against the distal tibia, producing an oblique shear fracture of the body of the talus. The shear fracture can be a coronal shear or a sagittal shear. In most instances of talar body fracture, there is significant displacement of the fragments with concurrent subluxation of the ankle or subtalar joints. In our case it was difficult to ascertain the initial displacement of the body of talus as there were no films showing the initial displacement, but it is possible that the talus was protruding from the wound and was mistaken as the lower end of fibula. Owing to its central functions, fractures of the talar body often involve appreciable disability, and this is further accen-
K. Shah, A. Hakmi / The Foot 14 (2004) 169–172
Fig. 2. On-table AP and lateral films of the ankle—fracture of the body of the talus, splitting it into two parts.
171
172
K. Shah, A. Hakmi / The Foot 14 (2004) 169–172
Fig. 3. Post-operative AP and lateral films showing the internal fixation of the fracture of the talus and the medial malleolus.
tuated by the special vascularization conditions which arise in certain regional injuries, involving a marked risk of avascular necrosis of the body. Both osteonecrosis and arthritis of the ankle and subtalar joints occur often, resulting in disabling pain because of the critical function of these articulations in gait (Sneppen and Buhl, 1974) [2]. Late results are characterized by appreciable subjective complaints and rehabilitation difficulties. Outcomes vary widely and are related to the degree of initial fracture displacement. Failure to recognize fracture displacement (even when minimal) can lead to under treatment and poor outcomes [3]. Sneppen et al. [4], who have done the best review of 31 patients, have recommended ‘exact reduction and stable fixation wherever possible.’ Even after restoration of congruity
of adjacent joints, early complications are not infrequent and most patients have development of radiographic evidence of osteonecrosis and/or post-traumatic arthritis [5]. These complications are worse after open fractures [5]. Interestingly, medial malleolar osteotomy is recommended for better exposure of the body of talus (in our case, patient had a fracture of the medial malleolus). Osteonecrosis may be less likely to occur when fracture of the talus is accompanied by a fracture of the malleoli, which preserves the soft-tissue attachments to the talar-body fragments. Overall we are reporting an unusual combination of fracture dislocation of talus with fracture of medial malleolus, which is hitherto, unreported. The mechanism of injury was fairly common, and the fracture of talus could have been missed, leading to potentially disastrous consequences. We hope this will help us to remind ourselves that fracture of talus can be a part of a ‘common’ ankle injury, and clinical examination of ankle injuries should also address the talus, apart from the fibula and the fifth metatarsal [6]. We believe that some of the “ankle sprains” that we come across so often, may have subtle injuries to the talus. Because fracture of the body of talus has a high incidence of complications, we need to make all efforts to diagnose it as early as possible and counsel the patient regarding these devastating injuries and their poor prognosis and potential complications. The long-term outcome of this patient is still awaited.
References [1] J.D. Michelsen, U.M. Ahn, S.L. Helgemo, Motion of the ankle in a simulated supination-external rotation fracture model, J. Bone Joint Surg. Am. 78 (7) (1996) 1024–1031. [2] O. Sneppen, O. Buhl, Fracture of the Talus-A study of its genesis and morphology based upon cases with associated ankle fracture, Acta Orthop. Scand. 45 (1974) 307–320. [3] P.T. Fortin, J.E. Balazsy, Talus fracture: evaluation and treatment, J. Am. Acad. Orthop. Surg. 9 (2) (2001) 114–127. [4] O. Sneppen, S.B. Christensen, O. Krosgoe, J. Lorentzes, Fracture of the body of the Talus, Acta Orthop. Scand. 48 (1977) 317–324. [5] H.A. Vallier, S.E. Nork, S.K. Benirschke, Surgical treatment of talar body fractures, J. Bone Joint Surg. Am. 85-A (9) (2003) 1716–1724. [6] G. Mollenhoff, J. Richter, G. Muhr, Supination trauma. A classic case, Orthopade 28 (6) (1999) 469–475.