507105
research-articleXXXX
FASXXX10.1177/1938640013507105Foot & Ankle SpecialistFoot & Ankle Specialist
vol. 7 / no. 1
Foot & Ankle Specialist
〈 Case Report 〉 Total Dislocation of the Talus
Shashi Kumar Nanjayan, MRCS Ed, John Broomfield, MRCS Ed, Benjamin Johnson, MRCS, Amit Patel, MRCS, Subodh Srivastava, FRCS (Ortho), and Ashok Sinha, FRCS (Ortho)
A Case Report
Abstract: Total talar dislocation is a rare injury that is usually open. We report a case of closed anterolateral dislocation in a 19 year old, following a fall from a bicycle. He was treated with prompt closed reduction. A magnetic resonance imaging scan 6 months later showed no signs of avascular necrosis. At 2 years followup, the patient had a full, pain free, range of motion at the ankle and subtalar joints.
risk of avascular necrosis (AVN).4 Such injuries usually mandate surgical debridement and internal fixation. In a literature search we found only 6 cases of closed total talar dislocation, without concomitant talar or malleolar fracture, treated by closed reduction.3,5-7 In this report, we present our treatment of a case of closed total talar dislocation, by closed reduction and discuss the outcome.
Levels of Evidence: Therapeutic, Level IV: Case Study
Case Report
Keywords: trauma; general disorders; talar fractures; forefoot; toe, midfoot
D
islocation of the talus from all 3 of its articulations (ie, with the tibia, calcaneus, and navicular) is termed total talus dislocation. It is an extremely rare injury, comprising only 3.4% of all major talar injuries (defined as dislocations, fractures, and fracturedislocations).1 Total talar dislocation is usually an open injury and is commonly associated with fracture of the talus itself or nearby structures including the malleoli, navicular, or calcaneus.2,3 The talus is notorious for its problematic vascularity and as a result there is a high
“
the left foot and ankle revealed a total (anterolateral) talar dislocation (Figure 1B and C) and a fracture of the base of the fifth metatarsal. There were no talar or malleolar fractures. The patient was transferred to the operating theatre for closed manipulation under anesthesia performed according to a technique described by Mitchell in 1936.8 An assistant maintained knee flexion at 90°, so as to relax the posterior
The talus is notorious for its
We report the case of a 19-year-old male, who fell problematic vascularity and as a result from a bicycle travelling at there is a high risk of avascular necrosis.” an estimated speed of 15 mph while trying to jump from a ramp. He landed on the lateral aspect of the foot sustaining a leg muscles and provide countertraction forced supination injury to the left ankle. to the primary surgeon, who provided longitudinal traction, by holding the foot He was unable to weight bear following and heel in a neutral position. After a the injury and presented to the suitable period of traction, initial emergency department with a painful, swollen foot and ankle. medially directed pressure was applied Initial assessment by Advanced Trauma to the talus from its lateral aspect, Life Support survey showed no other followed by addition of posteriorly injury. Clinical examination revealed a directed pressure. This was sufficient to swollen foot and ankle with no open achieve spontaneous reduction. injury (Figure 1A). There was no distal Satisfactory position was confirmed using image intensifier in theatre (Figure 2A neurovascular deficit and no evidence of and B). The ankle was then screened compartment syndrome. Radiographs of
DOI: 10.1177/1938640013507105. From the Royal Derby Hospital, Derby, UK (SKN, JB) and Mid Staffs NHS Foundation Trust, Staffordshire, UK (BJ, AP, SS, AS). Address correspondence to Shashi Kumar Nanjayan, MRCS Ed, Royal Derby Hospital, 47, Manor Park Court, Uttoxeter New Road, Derby DE22 3NG, UK; e-mail: shashikumartn@ gmail.com For reprints and permissions queries, please visit SAGE’s Web site at http://www.sagepub.com/journalsPermissions.nav. Copyright © 2013 The Author(s)
Downloaded from fas.sagepub.com by guest on June 14, 2015
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Figure 1. (A) Clinical appearance at presentation. (B) Initial injury radiograph AP view. (C) Initial injury radiograph lateral view.
Figure 2. Post-reduction radiographs.
through a range of motion under image intensifier control and no instability was demonstrated. Postoperatively the foot was immobilized in a below knee, non–weight bearing, plaster. A computed tomography scan performed the following day confirmed congruent reduction of the talus with no associated fracture and the patient was discharged home. Radiographs were taken 3 weeks later showing maintenance of reduction and a further 3 weeks non–weight bearing immobilization was advised. After a total of 6 weeks the plaster was removed and the patient commenced full weight bearing mobilization with
physiotherapy support. At 6-month follow-up the patient had no ankle or subtalar joint pain and had a full range of ankle and subtalar motion. Magnetic resonance imaging confirmed no evidence of AVN of the talus (Figure 3A and 3B). At 2-year follow-up the patient had returned to all activities without any pain or instability of the ankle or hindfoot and there were no radiographic features of osteoarthritis.
Discussion Anterolateral dislocations of the talus are the most common9 and occur as a
Downloaded from fas.sagepub.com by guest on June 14, 2015
result of excessive supination.10 Although rare, total talar dislocation is a severe injury, as all the vascular connections can be disrupted.9 The talus has complex articulations covering up to 80% of its surface, leaving only a small area for vascular penetration.11 The blood supply to the talus is diffuse and can be considered as extraosseous or intraosseous. The extraosseous supply arises from the posterior tibial, anterior tibial, and peroneal arteries, whereas the intraosseous supply arises from the anterior tibial artery and the artery of the tarsal sinus. Anastamoses of all the talar vessels are common, and Mulfinger and Trueta found they were present in 18 of the 30 specimens they examined and that they were extremely variable in nature.12 In a review of talar injuries over 16 years, Wagner et al treated only 6 total talus dislocations. All were of differing severity and direction and all required open reduction. They reported unanimously poor outcomes.13 In his 1988 series, Ritsema reported AVN in about half of cases where there was no talar neck fracutre,14 and Schiffer et al reported that neovascularization of the entire talus is possible through rarefied, apparently less important vessels, but this depends on comprehensive soft tissue management.11
vol. 7 / no. 1
Foot & Ankle Specialist
fracture. Open or closed treatment? Report of two cases and review of the literature. Open Orthop J. 2009;3:52-55. doi:10.2174/ 1874325000903010052.
Figure 3. Follow-up MRI.
5. Gaskin JSH, Pimple MK. Closed total talus dislocation without fracture: report of two cases. Eur J Orthop Surg Traumatol. 2007;17:409-411. doi:10.1007/s00590-0060187-8. 6. Pavic´ R. Talocalcaneal transfixation in total dislocation of the talus and subtalar dislocations. Mil Med. 2009;174:324-327. 7. Newcomb WJ, Brav EA. Complete dislocation of the talus. J Bone Joint Surg Am. 1948;30:872-874. 8. Mitchell J. Total dislocation of the astralgus. J Bone Joint Surg. 1936;18:212-214. 9. Maffulli N, Francobandiera C, Lepore L, Cifarelli V. Total dislocation of the talus. J Foot Surg. 1989;28:208-212.
The majority of total talar dislocations are associated with open injury or fracture, where surgery is mandatory. With only 6 other reports of similar cases,2,15-17 estimation of the true incidence of AVN following closed total talar dislocation is difficult. Progression to AVN depends on the amount of remaining blood suppy.4 It follows that, in closed total dislocations, attempts should first be made at closed reduction,3,7 in order to prevent surgical division of the surviving vascular structures and thus protect the remaining blood supply. The first radiologic sign of AVN can be observed anywhere between 4 weeks and 6 months after the accident,18 and it is important to consider this during the follow-up period with serial radiographs or magnetic resonance imaging.6 Postoperative weight bearing status remains a contentious issue, although favorable outcomes have been demonstrated in the literature after early weight bearing.3,8,19 Posttraumatic arthritis may occur in any, and all, joints involved,3 but if fracture is not present this is extremely difficult to predict.
It is our strong opinion that the favorable outcome in this case is most likely to be due to the avoidance of surgical violation of tissues around the talus that contained its remaining vascular supply. This case demonstrates that early reduction by closed means represents a safe and effective treatment of this rare, and potentially disastrous, problem. If the joint is stable after reduction then 6 weeks non–weight bearing immobilization in cast followed by progression to weight bearing and serial radiographic assessment for AVN can be associated with good outcome.
10. Leitner B. The mechanism of total dislocation of the talus. J Bone Joint Surg Am. 1955;37:89-95. 11. Schiffer G, Jubel A, Elsner A, Andermahr J. Complete talar dislocation without late osteonecrosis: clinical case and anatomic study. J Foot Ankle Surg. 2007;46:120-123. doi:10.1053/j.jfas.2006.11.004. 12. Mulfinger GL, Trueta J. The blood supply of the talus. J Bone Joint Surg Br. 1970;52:160-167. 13. Wagner R, Blattert TR, Weckbach A. Talar dislocations. Injury. 2004;35(suppl 2):SB36SB45. doi:10.1016/j.injury.2004.07.010. 14. Ritsema GH. Total talar dislocation. J Trauma. 1988;28:692-694.
References
15. Heylen S, De Baets T, Verstraete P. Closed total talus dislocation: a case report. Acta Orthop Belg. 2011;77:838-842.
1. Kenwright J, Taylor RG. Major injuries of the talus. J Bone Joint Surg Br. 1970;52: 36-48.
16. Krasin E, Goldwirth M, Otremski I. Complete open dislocation of the talus. J Accid Emerg Med. 2000;17:53-54.
2. Hiraizumi Y, Hara T, Takahashi M, Mayehiyo S. Open total dislocation of the talus with extrusion (missing talus): report of two cases. Foot Ankle. 1992;13:473-477.
17. Van Opstal N, Vandeputte G. Traumatic talus extrusion: case reports and literature review. Acta Orthop Belg. 2009;75:699-704.
3. Taymaz A, Gunal I. Complete dislocation of the talus unaccompanied by fracture. J Foot Ankle Surg. 2005;44:156-158. doi:10.1053/j.jfas.2005.01.008. 4. Xarchas KC, Psillakis IG, Kazakos KJ, Pelekas S, Ververidis AN, Verettas DA. Total dislocation of the talus without a
Downloaded from fas.sagepub.com by guest on June 14, 2015
18. McNerney JE. The incidence of aseptic necrosis of the talus following traumatic injuries: a review of the literature. J Foot Surg. 1978;17:137-143. 19. Mestdagh H, Duquennoy A, Claisse PR, Sensey JJ, Gougeon F. Long-term prognosis of tarsal dislocations. Arch Orthop Trauma Surg. 1982;99:153-159.
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research-articleXXXX
FASXXX10.1177/1938640013507105Foot & Ankle SpecialistFoot & Ankle Specialist
vol. 7 / no. 1
Foot & Ankle Specialist
〈 Case Report 〉 Total Dislocation of the Talus
Shashi Kumar Nanjayan, MRCS Ed, John Broomfield, MRCS Ed, Benjamin Johnson, MRCS, Amit Patel, MRCS, Subodh Srivastava, FRCS (Ortho), and Ashok Sinha, FRCS (Ortho)
A Case Report
Abstract: Total talar dislocation is a rare injury that is usually open. We report a case of closed anterolateral dislocation in a 19 year old, following a fall from a bicycle. He was treated with prompt closed reduction. A magnetic resonance imaging scan 6 months later showed no signs of avascular necrosis. At 2 years followup, the patient had a full, pain free, range of motion at the ankle and subtalar joints.
risk of avascular necrosis (AVN).4 Such injuries usually mandate surgical debridement and internal fixation. In a literature search we found only 6 cases of closed total talar dislocation, without concomitant talar or malleolar fracture, treated by closed reduction.3,5-7 In this report, we present our treatment of a case of closed total talar dislocation, by closed reduction and discuss the outcome.
Levels of Evidence: Therapeutic, Level IV: Case Study
Case Report
Keywords: trauma; general disorders; talar fractures; forefoot; toe, midfoot
D
islocation of the talus from all 3 of its articulations (ie, with the tibia, calcaneus, and navicular) is termed total talus dislocation. It is an extremely rare injury, comprising only 3.4% of all major talar injuries (defined as dislocations, fractures, and fracturedislocations).1 Total talar dislocation is usually an open injury and is commonly associated with fracture of the talus itself or nearby structures including the malleoli, navicular, or calcaneus.2,3 The talus is notorious for its problematic vascularity and as a result there is a high
“
the left foot and ankle revealed a total (anterolateral) talar dislocation (Figure 1B and C) and a fracture of the base of the fifth metatarsal. There were no talar or malleolar fractures. The patient was transferred to the operating theatre for closed manipulation under anesthesia performed according to a technique described by Mitchell in 1936.8 An assistant maintained knee flexion at 90°, so as to relax the posterior
The talus is notorious for its
We report the case of a 19-year-old male, who fell problematic vascularity and as a result from a bicycle travelling at there is a high risk of avascular necrosis.” an estimated speed of 15 mph while trying to jump from a ramp. He landed on the lateral aspect of the foot sustaining a leg muscles and provide countertraction forced supination injury to the left ankle. to the primary surgeon, who provided longitudinal traction, by holding the foot He was unable to weight bear following and heel in a neutral position. After a the injury and presented to the suitable period of traction, initial emergency department with a painful, swollen foot and ankle. medially directed pressure was applied Initial assessment by Advanced Trauma to the talus from its lateral aspect, Life Support survey showed no other followed by addition of posteriorly injury. Clinical examination revealed a directed pressure. This was sufficient to swollen foot and ankle with no open achieve spontaneous reduction. injury (Figure 1A). There was no distal Satisfactory position was confirmed using image intensifier in theatre (Figure 2A neurovascular deficit and no evidence of and B). The ankle was then screened compartment syndrome. Radiographs of
DOI: 10.1177/1938640013507105. From the Royal Derby Hospital, Derby, UK (SKN, JB) and Mid Staffs NHS Foundation Trust, Staffordshire, UK (BJ, AP, SS, AS). Address correspondence to Shashi Kumar Nanjayan, MRCS Ed, Royal Derby Hospital, 47, Manor Park Court, Uttoxeter New Road, Derby DE22 3NG, UK; e-mail: shashikumartn@ gmail.com For reprints and permissions queries, please visit SAGE’s Web site at http://www.sagepub.com/journalsPermissions.nav. Copyright © 2013 The Author(s)
Downloaded from fas.sagepub.com by guest on June 14, 2015
71
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February 2014
Foot & Ankle Specialist
Figure 1. (A) Clinical appearance at presentation. (B) Initial injury radiograph AP view. (C) Initial injury radiograph lateral view.
Figure 2. Post-reduction radiographs.
through a range of motion under image intensifier control and no instability was demonstrated. Postoperatively the foot was immobilized in a below knee, non–weight bearing, plaster. A computed tomography scan performed the following day confirmed congruent reduction of the talus with no associated fracture and the patient was discharged home. Radiographs were taken 3 weeks later showing maintenance of reduction and a further 3 weeks non–weight bearing immobilization was advised. After a total of 6 weeks the plaster was removed and the patient commenced full weight bearing mobilization with
physiotherapy support. At 6-month follow-up the patient had no ankle or subtalar joint pain and had a full range of ankle and subtalar motion. Magnetic resonance imaging confirmed no evidence of AVN of the talus (Figure 3A and 3B). At 2-year follow-up the patient had returned to all activities without any pain or instability of the ankle or hindfoot and there were no radiographic features of osteoarthritis.
Discussion Anterolateral dislocations of the talus are the most common9 and occur as a
Downloaded from fas.sagepub.com by guest on June 14, 2015
result of excessive supination.10 Although rare, total talar dislocation is a severe injury, as all the vascular connections can be disrupted.9 The talus has complex articulations covering up to 80% of its surface, leaving only a small area for vascular penetration.11 The blood supply to the talus is diffuse and can be considered as extraosseous or intraosseous. The extraosseous supply arises from the posterior tibial, anterior tibial, and peroneal arteries, whereas the intraosseous supply arises from the anterior tibial artery and the artery of the tarsal sinus. Anastamoses of all the talar vessels are common, and Mulfinger and Trueta found they were present in 18 of the 30 specimens they examined and that they were extremely variable in nature.12 In a review of talar injuries over 16 years, Wagner et al treated only 6 total talus dislocations. All were of differing severity and direction and all required open reduction. They reported unanimously poor outcomes.13 In his 1988 series, Ritsema reported AVN in about half of cases where there was no talar neck fracutre,14 and Schiffer et al reported that neovascularization of the entire talus is possible through rarefied, apparently less important vessels, but this depends on comprehensive soft tissue management.11
vol. 7 / no. 1
Foot & Ankle Specialist
fracture. Open or closed treatment? Report of two cases and review of the literature. Open Orthop J. 2009;3:52-55. doi:10.2174/ 1874325000903010052.
Figure 3. Follow-up MRI.
5. Gaskin JSH, Pimple MK. Closed total talus dislocation without fracture: report of two cases. Eur J Orthop Surg Traumatol. 2007;17:409-411. doi:10.1007/s00590-0060187-8. 6. Pavic´ R. Talocalcaneal transfixation in total dislocation of the talus and subtalar dislocations. Mil Med. 2009;174:324-327. 7. Newcomb WJ, Brav EA. Complete dislocation of the talus. J Bone Joint Surg Am. 1948;30:872-874. 8. Mitchell J. Total dislocation of the astralgus. J Bone Joint Surg. 1936;18:212-214. 9. Maffulli N, Francobandiera C, Lepore L, Cifarelli V. Total dislocation of the talus. J Foot Surg. 1989;28:208-212.
The majority of total talar dislocations are associated with open injury or fracture, where surgery is mandatory. With only 6 other reports of similar cases,2,15-17 estimation of the true incidence of AVN following closed total talar dislocation is difficult. Progression to AVN depends on the amount of remaining blood suppy.4 It follows that, in closed total dislocations, attempts should first be made at closed reduction,3,7 in order to prevent surgical division of the surviving vascular structures and thus protect the remaining blood supply. The first radiologic sign of AVN can be observed anywhere between 4 weeks and 6 months after the accident,18 and it is important to consider this during the follow-up period with serial radiographs or magnetic resonance imaging.6 Postoperative weight bearing status remains a contentious issue, although favorable outcomes have been demonstrated in the literature after early weight bearing.3,8,19 Posttraumatic arthritis may occur in any, and all, joints involved,3 but if fracture is not present this is extremely difficult to predict.
It is our strong opinion that the favorable outcome in this case is most likely to be due to the avoidance of surgical violation of tissues around the talus that contained its remaining vascular supply. This case demonstrates that early reduction by closed means represents a safe and effective treatment of this rare, and potentially disastrous, problem. If the joint is stable after reduction then 6 weeks non–weight bearing immobilization in cast followed by progression to weight bearing and serial radiographic assessment for AVN can be associated with good outcome.
10. Leitner B. The mechanism of total dislocation of the talus. J Bone Joint Surg Am. 1955;37:89-95. 11. Schiffer G, Jubel A, Elsner A, Andermahr J. Complete talar dislocation without late osteonecrosis: clinical case and anatomic study. J Foot Ankle Surg. 2007;46:120-123. doi:10.1053/j.jfas.2006.11.004. 12. Mulfinger GL, Trueta J. The blood supply of the talus. J Bone Joint Surg Br. 1970;52:160-167. 13. Wagner R, Blattert TR, Weckbach A. Talar dislocations. Injury. 2004;35(suppl 2):SB36SB45. doi:10.1016/j.injury.2004.07.010. 14. Ritsema GH. Total talar dislocation. J Trauma. 1988;28:692-694.
References
15. Heylen S, De Baets T, Verstraete P. Closed total talus dislocation: a case report. Acta Orthop Belg. 2011;77:838-842.
1. Kenwright J, Taylor RG. Major injuries of the talus. J Bone Joint Surg Br. 1970;52: 36-48.
16. Krasin E, Goldwirth M, Otremski I. Complete open dislocation of the talus. J Accid Emerg Med. 2000;17:53-54.
2. Hiraizumi Y, Hara T, Takahashi M, Mayehiyo S. Open total dislocation of the talus with extrusion (missing talus): report of two cases. Foot Ankle. 1992;13:473-477.
17. Van Opstal N, Vandeputte G. Traumatic talus extrusion: case reports and literature review. Acta Orthop Belg. 2009;75:699-704.
3. Taymaz A, Gunal I. Complete dislocation of the talus unaccompanied by fracture. J Foot Ankle Surg. 2005;44:156-158. doi:10.1053/j.jfas.2005.01.008. 4. Xarchas KC, Psillakis IG, Kazakos KJ, Pelekas S, Ververidis AN, Verettas DA. Total dislocation of the talus without a
Downloaded from fas.sagepub.com by guest on June 14, 2015
18. McNerney JE. The incidence of aseptic necrosis of the talus following traumatic injuries: a review of the literature. J Foot Surg. 1978;17:137-143. 19. Mestdagh H, Duquennoy A, Claisse PR, Sensey JJ, Gougeon F. Long-term prognosis of tarsal dislocations. Arch Orthop Trauma Surg. 1982;99:153-159.
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