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Medial Subtalar Dislocation of the Foot Associated with an Acute Compartment Syndrome: A Case Report

Posted on June 1, 2013 | Comments Off on Medial Subtalar Dislocation of the Foot Associated with an Acute Compartment Syndrome: A Case Report

by Muzamil Ahmad Baba1, M. A Halwai2, B.A Mir3, Adil Bashir4, Mubashir Wani5pdflrg

The Foot and Ankle Online Journal 6 (6): 1

Subtalar dislocation an uncommon injury, accounts for approximately 1% to 2% of all joint dislocations. Subtalar dislocation, also known as peritalar dislocation, refers to the simultaneous dislocation of the distal articulations of the talus at the talocalcaneal and talonavicular joints. This case report presents a rare situation of a medial subtalar dislocation complicated by an acute compartment syndrome that required an urgent fasciotomy which has never been reported before.

Key words: Subtalar dislocation, Compartment syndrome, Closed reduction, Fasciotomy.

Accepted: May, 2013
Published: June, 2013

ISSN 1941-6806
doi: 10.3827/faoj.2013.0606.001

Address correspondence to: Dr. Muzamil Ahmad Baba, Govt. Hospital for Bone and Joint Surgery Barzullah, Srinagar India, 190005. Mobile 9086181281. muzamilbaba79@yahoo.com.

1Orthopaedic Resident, Govt. Hospital for Bone and joint surgery Srinagar.
2Proffessor and Head Orthopaedics, Govt. Hospital for Bone and joint surgery Srinagar. drmahalwai@rediffmail.com

The subtalar dislocation occurs through the disruption of 2 separate bony articulations, the talonavicular and talocalcaneal joints.[1,2] These joints act as a hinge that transmits load and movement from the foot to the ankle. Subtalar dislocation is an uncommon injury that disturbs the normal anatomy and function of these joints. The medial dislocation, also known as an acquired clubfoot, is the most common of all subtalar dislocations, comprising approximately 80% to 85% of the cases.[3] The medial dislocation occurs through forceful inversion of the forefoot with the talar neck pivoting on the sustentaculum tali, which acts as a fulcrum to lever the calcaneus from the talus.

Initially, it is believed that the talonavicular joint is the first to dislocate, followed by rotary subluxation through the subtalar joint, with the talar head finally coming to rest between the extensor hallucis longus and the extensor digitorum longus on either the cuboid or navicular.[4] We present a rare case report of a 36-year-old male with a medial subtalar dislocation that was complicated by an acute compartment syndrome of the foot.

Case Report

A 36-year-old male presented to our hospital 12 hours after sustaining trauma to his right foot due to a twisting injury in his farm when he was carrying a heavy load over his right shoulder. He also gave a history of some manipulation by a quack, which did not give him any relief, but the intensity of pain increased following manipulation.

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Figure 1 The anteroposterior and Lateral radiograph of right foot showing a medial subtalar dislocation.

On examination, the patient was fully conscious and local examination revealed a deformity of the right foot with a prominence medially with tense swelling of the foot. Immediate radiographs in the emergency revealed a medial subtalar dislocation. (Fig.1) The dislocation was reduced in the emergency without anesthesia with gentle longitudinal and lateral traction of the foot, resulting in anatomic reduction of the talocalcaneal and talonavicular joints. (Fig.2) A posterior splint was applied and the limb was kept elevated and patient was observed every 15 minutes for two hours. The patient continued with pain, marked swelling encompassed the entire foot, with relative sparing of the digits. Sensation to pin prick was present to all the toes and web spaces, but two point discrimination was diminished. Pain on passive motion of the toes was present. The medial-plantar aspect of the foot (medial compartment) was particularly tense and swollen.

Severe bruising of the foot was evident. Further, there was pitting edema on the dorsum of the foot. (Fig.3 and 4) The toes were slightly pale and capillary refill was approximately 3 seconds on right and < less than 2 seconds on left foot. Sensory examination revealed continued paresthesia in the same distribution. After clinical examination, a decision for a fasciotomy was made. Intra-operatively tense compartment was confirmed and bulging muscle was noted in the medial incision.

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Figure 2 Immediate Post reduction anteroposterior and lateral radiograph of same patient.

Immediately postoperatively, the foot was placed in a well-padded splint, elevated, and intravenous antibiotics administered (cefazolin). Five days later, the fasciotomy wounds were closed. The patient was discharged on the day following fasciotomy closure. Follow-up at 2 years revealed well-healed incisions, absence of neuromuscular deficits with excellent functional recovery with no signs of AVN of the talus.

Discussion

Subtalar dislocations are rare, accounting for only 1% to 2% of all dislocations.[1] Smith noted only seven dislocations in a review of 535 dislocations of all types.[5] Leitner noted only 42 among 4215 dislocations.[6] Although first described in 1811 by Judcy and Dufaurets, it involves the disruption of the talocalcaneal and talonavicular joints, while the calcaneocuboid joint remains intact.[6]

STDisFig3 STDisFig4
Figure 3 and 4 Clinical photographs of patient showing tense foot compartment prior to fasciotomy.

Subtalar dislocation can occur in any direction. Significant deformity is always present. Up to 85% of dislocations are medial.[3] The calcaneus, with the rest of the foot is displaced medially while the talar head is prominent in the dorsolateral aspect of the foot. The navicular is medial and sometimes dorsal to the talar head and neck. Lateral dislocation occurs less often. In a lateral dislocation, the calcaneus is displaced lateral to the talus and the talar head is prominent medially. The navicular lies lateral to the talar neck. Rarely, a subtalar dislocation is reported to occur in a direct anterior or posterior direction, but these are usually associated with medial or lateral displacement as well. The direction of subtalar dislocation has important effects with respect to management and outcome. The method of reduction is different for each type of injury.

Radiographs of a subtalar dislocation may be difficult to interpret. The severity of the deformity makes it difficult to obtain true anteroposterior and lateral images of the foot, and standard ankle radiographs do not reveal the foot pathology.[7]

It is important to note that the relationship between the talus and tibia and fibula is normal in a peritalar dislocation because the point of injury is distal to the ankle joint. The anteroposterior view of the foot demonstrates the talonavicular dislocation. Usually interpretation of the plain radiographs provides enough information to determine the direction of the dislocation, such that the physician can proceed with an attempt at reduction.

All subtalar dislocations require a gentle and timely reduction. In most cases, reduction can be accomplished closed. Often the injury presents with skin tenting such that a prompt reduction will reduce the possibility of skin necrosis. Once the reduction is accomplished, it should be confirmed by clinical examination and radiographs. The outcome following simple dislocations treated with closed reduction seems to be favorable.[8] In some series, as few as 10% of patients with medial dislocations and 15% to 20% of lateral subtalar dislocations required open reduction.[6] Recent series, particularly from trauma centers, have noted the need for open reduction to be more common, with 32% of patients requiring open reduction in one series.[9] A variety of bone and soft tissue structures may become entrapped, resulting in a block to closed reduction. These impediments require open manipulation or release to facilitate reduction.

Subtalar dislocations have a wide variance in terms of their prognosis. Uncomplicated subtalar dislocations, stable following a closed reduction, have an excellent prognosis with minimal symptoms at long-term follow-up.[8] Certain subtalar dislocations are clearly associated with a worse prognosis. Lancaster, et al., in a review of the literature, noted that associated injuries and complications were associated with a worse result. In particular, soft tissue injury, extra-articular fracture, intra-articular fracture, and osteonecrosis were associated with a worse outcome.[10] Open fractures are undoubtedly associated with the poorest results. Goldner et al., reviewed 15 patients at a mean of 18 years following open subtalar dislocations. Associated injuries were noted to the tibial nerve in 10 patients; to the posterior tibial tendon in 5; and to the posterior tibial artery in 5. Seven patients ultimately required arthrodesis due to osteonecrosis or post traumatic arthritis.[11]

Osteonecrosis of the talus may develop following peritalar dislocations. Overall, osteonecrosis is uncommon and generally only noted with high-energy and open injuries. Theoretically, the talus is not displaced from the ankle mortise and therefore at least some of the blood supply should be preserved. However, Goldner, et al., noted osteonecrosis in 5 of 15 patients with grade 3 open subtalar dislocations.[11] In addition, Bibbo, et al., also observed osteonecrosis in three patients.[9] Although our case was complicated by development of a compartment syndrome but timely intervention resulted in an excellent result in our case.

Conclusion

The majority of subtalar dislocations can be treated in a closed manner with a period of nonweight bearing and immobilization with satisfactory results. Occasionally, these patients may develop a compartment syndrome which, if not treated in time, may lead to catastrophic results. A high clinical suspicion and observation is warranted especially in cases with delayed presentation to diagnose such a condition early and manage it in a timely manner.

References

1. Perugia D, Basile A, Massoni C, Gumina S, Rossi F, Ferretti A. Conservative treatment of subtalar dislocations. Int Orthop 2002 26: 56-60. [PubMed]
2. Barber JR, Bricker JD, Haliburton RA. Peritalar dislocation of the foot. Can J Surg 1961 4: 205-210. [PubMed]
3. Monson ST, Ryan JR. Subtalar dislocation. JBJS 1981 63A: 1156-1158. [PubMed]
4. Buckingham WW Jr, LeFlore I. Subtalar dislocation of the foot. J Trauma 1973 13: 753-765. [PubMed]
5. Smith H. Subastragalar dislocation: a report of seven cases. JBJS 1937 19B: 373-380.[Website]
6.  Leitner B. Obstacles to reduction in subtalar dislocations. JBJS 1954 36A: 299-306. [PubMed]
7. Gross RH. Medial peritalar dislocation, associated foot injuries and mechanism of injury. J Trauma 1975 15: 682-688.[PubMed]
8. Delee JC, Curtis R. Subtalar dislocation of the foot. JBJS 1982 64A: 433-437. [PubMed]
9. Bibbo C, Anderson RB, Davis WH. Injury characteristics and the clinical outcome of subtalar dislocations: a clinical and radiographic analysis of 25 cases. Foot Ankle Int 2003 24:158-163. [PubMed]
10. Lancaster S, Horowitz M, Alonso J. Subtalar dislocations: a prognosticating classification. Orthopedics 1985 8:1234-1240. [PubMed]
11. Goldner JL, Poletti SC, Gates HS 3rd, et al. Severe open subtalar dislocations. Long-term results. JBJS 1995 77A: 1075-1079. [PubMed]

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Lateral Subtalar Dislocation of the Foot: A case report

Posted on November 1, 2011 | Comments Off on Lateral Subtalar Dislocation of the Foot: A case report

by Dr. M.R.Jayaprakash 1, Dr.Vijaykumar Kulumbi 2, Dr.Ashok Sampagar 3, Dr.Chetan Umarani 4

The Foot and Ankle Online Journal 4 (11): 1

Subtalar dislocation, also known as peritalar dislocation, refers to the simultaneous dislocation of the distal articulations of the talus at the talocalcaneal and talonavicular joints. Subtalar dislocation can occur medially or laterally with resulting deformity. Medial dislocations comprise up to 85% of subtalar dislocations whilst lateral subtalar dislocations are less frequent and in 15% to 20% of dislocations. Closed reduction and immobilization remains the treatment of choice. The tibialis posterior, talar head impaction, and entrapment of the joint capsule may cause difficulty in closed reduction of lateral dislocations; hence open reduction may be necessary. This case report presents an unsuccessful closed reduction of a lateral subtalar dislocation which required an open reduction technique using wire stabilization.

Key words: Subtalar dislocation, talus, trauma, closed reduction, open reduction.

Accepted: October, 2011
Published: November, 2011

ISSN 1941-6806
doi: 10.3827/faoj.2011.0411.0001

Subtalar dislocation is a rare rearfoot injury, it disturbs the normal anatomy and function between the talus, calcaneus and navicular bone. [1,2,3,7,10] The talocal-caneal and talonavicular joints can be dislocated simultane¬ously, without a fracture of the neck of the talus .This has also been referred to as a peritalar or subastragalar dislocation. [4]

Although some dislocations may completely reduce or even partially reduce on its own, there are basically two types of subtalar dislocation reported in the literature. In lateral subtalar dislocation, the head of talus is found medially and the rest of the foot is dislocated laterally. In medial subtalar dislocation, the head of the talus is found laterally and the rest of the foot is dislocated medially. [4,6]

However, in a lateral subtalar dislocation, the talus can remain fixed while the remaining structures of the foot are dislocated laterally along the talus. It is important to check the stability and congruity of the talus in the ankle mortise with any subtalar dislocation.

Subtalar dislocations present with an impressive amount of deformity. Medial dislocation has been referred to as an “acquired clubfoot”, while the lateral injury is described as an “acquired flatfoot”. [6,7] Lateral dislocations are particularly prone to poor results, due to the frequency of open injuries and associated fractures4. We report a case of lateral subtalar dislocation in 35 year-old man in whom closed reduction was unsuccessful hence open reduction was performed.

Case Report

A 35 year-old man, who sustained a high energy trauma while travelling on a two-wheeler. He was then hit by an oncoming tractor. He presented to Bapuji Hospital. The foot was diffusely swollen with a laceration over the medial border of the foot. The skin was distorted and markedly tented over the prominent head of the talus which was felt medially. The posterior tibial artery was not palpable due to severe swelling and the dorsalis pedis artery was palpable. Radiographs showed that the foot along with calcaneum had moved laterally off the talus. (Figs. 1A, 1B and 1C)

  

Figures 1A, 1B and 1C Radiographs showing talonavicular dislocation. (A and B).  Initial radiograph showing lateral subtalar dislocation without signs of fracture.  The talus is displaced along the ankle mortise. (C)

Initially a closed reduction was attempted and this was unsuccessful. The patient was then prepared for surgery for open reduction and stabilization. A medial incision was performed extending the lacerated wound. The posterior tibial tendon was identified. The displaced talus was relocated into the joint after further dissection and reduction. The posterior tibial tendon was retracted and the talus was levered into the position and reduction was achieved. Reduction was confirmed using a computer assisted radio monitor (c- arm). (Fig. 2A and 2B) A thick Kirschner wire was inserted from the calcaneum into the talus to hold the reduction. A below knee splint was applied after placing sterile dressing on the operative site. The splint was then replaced with a windowed cast to inspect the incision daily.The operative reduction was successful. (Fig. 3A and 3B)

 

Figures 2A and 2B  Intraoperative radiographic scans showing insertion of Kirschner wire through the calcaneum.

 

Figures 3A and 3B Intraoperative photographs showing correction of deformity after the reduction of dislocation.

Discussion

Dislocation of the talus can occur in conjunction with major talus fractures. [5] However, dislocations can also occur with no associated bony injury or with relatively minimal appearing fractures. [3,4] Subtalar dislocation, also known as peritalar dislocation refers to the simultaneous dislocation of the distal articulations of the talus at the talocalcaneal and talonavicular joints. [4,6]

First described by Judcy and Dufaurets [7] in 1811, clinical reviews of subtalar dislocations are relatively infrequent and generally limited to small numbers of patients. Subtalar dislocation can occur in any direction. Significant deformity is always present. Up to 85% of dislocations are medial. [5,7] The calcaneus, with the rest of the foot is displaced medially while the talar head is prominent in the dorsolateral aspect of the foot. The navicular is medial and sometimes dorsal to the talar head and neck. Lateral dislocation occurs less often about 10-15%. [6,7,10]

In a lateral peritalar dislocation, the calcaneus and navicular is displaced lateral to the talus and the talar head is prominent medially. [4,10] Rarely, a subtalar dislocation is reported to occur in a direct anterior or posterior direction, [2,7] but these are usually associated with medial or lateral displacement as well.

Between 10% and 40% of subtalar dislocations are open. [13] Open injuries tend to occur more commonly with the lateral subtalar dislocation pattern and probably as the result of a more violent injury. Long term follow-up demonstrated very poor results with open subtalar dislocations. [13]

The majority of subtalar dislocations can be reduced in a closed manner in the emergency department with the use of local anesthesia and procedural sedation. Early reduction is essential to prevent loss of skin due to pressure necrosis from the underlying dislocation. [4]
In approximately 10% of medial subtalar dislocations and 15% to 20% of lateral dislocations, closed reduction cannot be achieved. [11,12] Soft tissue interposition and bony blocks have been identified as factors preventing closed reduction. [11] With medial dislocations, the talar head can become trapped by the capsule of the talonavicular joint, the extensor retinaculum or the extensor tendons, or the extensor digitorum brevis muscle. [11,12] With a lateral dislocation, the posterior tibial tendon may become when firmly entrapped and present as a barrier to closed and even open reduction. [7,12]

In 1954, Leitner [12] initially proposed a mechanism by which the flexor retinaculum is disrupted, allowing the tendon to drape over the talar head and preventing reduction. In 1982 DeLee, et al., [4] in their case series three of the four lateral disloca¬tions required open reduction. Of these three, the posterior tibial tendon was the obstructing agent in two and a fracture of the head of the talus prevented closed reduction in one.

In our case presentation, the patient had sustained high energy trauma. Initially a closed reduction was attempted, but was unsuccessful. In the open reduction, we identified the tibialis posterior tendon as obstructing the reduction. Open reduction with Kirschner wire or Steinman pin reduction is shown to successfully reduce a lateral subtalar dislocation in this case report.

References

1.Brunet P, Dubrana F, Burgand A, Nen De Le, Lefebre C. Subtalar dislocation: review of ten cases at mean ten-year follow-up. JBJS 2004 86B (Supp 1):57.
2. Lyrtzis CH, Papadopoulos A, Fotiadis E, Ntovas TH, Petridis P, Koimtzis M. Isolated medial subtalar dislocations -conservative treatment. EEXOT 2009: 195-198
3 Capelli RM, Galamnini V, Crespi L. Subtalar anterolateral dislocations: case report and literature review. J Orthop Traumatol 2002 3:181-183.
4. DeLee JC, Curtis R .Subtalar dislocations of the foot. JBJS 1982 64A: 433-437.
5. Monson ST, Ryan JR. Subtalar dislocation. JBJS 1981 63A: 1156-1158,
6. J. Terrence Jose Jerome, Mathew Varghese, Balu Sankaran, K. Thirumagal. Lateral subtalar dislocation of the foot: A case report. The Foot & Ankle Journal, 2008 1 (12): 2.
7. Sanders DW. Fractures of the talus. In: Bucholz RW, Heckman JD, Court-Brown C, eds. Rockwood and Green’s Fractures in Adults. Vol 1. 6th ed. Philadelphia, PA: Lippincott Williams & Wilkins, 2249-2292, 2006.
8. Plewes LW, McKelvey KG. Subtalar dislocation. JBJS 1944 26A: 585-588.
9. Smith H. Subastragalar dislocation: a report of seven cases. JBJS 1937 19A: 373-380
10. Joel Horning,John DiPreta .Subtalar Dislocation. Orthopedics 2009; 32:904
11. Mulroy, R. D.: The tibialis posterior tendon as an obstacle to reduction of a lateral anterior subtalar dislocation. JBJS 1955 37A: 859-863.
12. Leitner, L., Baldo: Obstacles to reduction in subtalar dislocations. JBJS 1954 36A: 299-306.
13. Goldner JL, Poletti SC, Gates HS 3rd, Richardson WJ. Severe open subtalar dislocations: long-term results. JBJS 1995 77A: 1075 -1079

Address correspondence to: Dr.M.R.Jayaprakash Ramakrishna, 43, PJ extension, 2nd main, 7th cross, Davanagere, Karnataka India 577002 . Phone (Mobile) – +919448667305, (Clinic) – 08192-253609, Email- umaranicm@gmail.com, ashok.samp@gmail.com

1  Professor and Unit Head,Department of Orthopaedics, JJM Medical College,Davangere, India 577004.
2  Professor of Department of Orthopaedics. JJM Medical College, Davangere, India 577004.
3  Resident in Orthopaedics. JJM Medical College. Davangere, India 577004.
4  Resident in Orthopaedics. JJM Medical College. Davangere, India 577004.

© The Foot and Ankle Online Journal, 2011

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Isolated complete plantar dislocation of first metatarsocuneiform (first tarsometatarsal) joint: A case report

Posted on December 1, 2010 | Comments Off on Isolated complete plantar dislocation of first metatarsocuneiform (first tarsometatarsal) joint: A case report

by Asif Sultan1 , Mohd Iqbal Wani1, Tahir Ahmad Dar1, Mubashir Maqbool Wani1, Samina Shafi2

The Foot and Ankle Online Journal 3 (12): 2

Isolated plantar dislocation of first metatarsocuneiform joint is a rare occurrence and only few have been reported till date to the best of our knowledge. We report such a case of traumatic isolated pure plantar dislocation of first metatarsocuneiform joint in a young otherwise normal patient who was managed by closed reduction. No complication was found and he returned to his pre injury status in 12 weeks with no sequelae found at 2 year follow up.

Key words: Metatarsocuneiform joint, plantar dislocation, tarsometatarsal joint, closed reduction.

Accepted: November, 2010
Published: December, 2010

ISSN 1941-6806
doi: 10.3827/faoj.2010.0312.0002

Dislocations of first metatarsocuneiform joint have been reported with addition of atypical medial, lateral and floating dislocations by several authors [1-6] usually in association with fractures of metatarsals or dislocations of other tarsometatarsal joints. However, the isolated plantar dislocation of the same joint is of an extremely rare occurrence. The authors present a case of traumatic isolated plantar dislocation of first metatarsocuneiform joint in a young otherwise normal patient who was managed by closed reduction.

Case Report

We received a case in our emergency room who had suffered trauma right foot. The patient complained of severe pain and inability to bear weight. The patient was a 22 year-old male Asian Indian in origin. The cause of the trauma was a 5 kilogram rounded iron weight (used for weighing different things in stores across rural India) which had fallen straight on the dorsum of his right foot. On examination there was an obvious deformity of the midfoot medially around first metatarsocuneiform (tarsometatarsal) junction. There was minimal swelling, but tenderness at first tarsometatarsal joint area. The dorsalis pedis pulsations were normal palpable and sensations of foot were normal. There were no signs of compartment syndrome of foot. There was no joint hyperlaxity associated.

Radiographs of the right foot were performed and the anteroposterior view and a lateral view showed planter dislocation of first metatarsocuneiform joint without any associated fracture of metatarsals or cuneiform. (Figs. 1A and 1B) The patient was taken to the operation theatre where under regional anaesthesia (ankle block) the dislocation was reduced anatomically and stability confirmed under C-arm and a short leg cast was given for 6 weeks. Partial weight bearing was started at 6 weeks progressing to full unsupported weight bearing at 12 weeks. The patient had an uneventful recovery and was asymptomatic at two year follow up with normal radiographs, a normal gait with well maintained medial longitudinal arch of foot. (Figs. 2A and 2B)

Figure 1A and 1B Anteroposterior (A) and Lateral (B) radiograph showing first metatarsocuneiform dislocation.

Figure 2A and 2B Anteroposterior (A) and Lateral (B) radiograph showing reduction of first metatarsocuneiform dislocation after 2 years.

Discussion

Dislocation of first metatarsocuineoform joint is a rare injury and it is usually associated with injuries to other tarsometatarsal joints including fractures and dislocations (Lisfranc’s fracture dislocation). These injuries may be caused by direct or indirect trauma, varying from low impact injuries such as twisting, to high impact injuries such as road traffic accidents and fall from height. Dislocation of metatarsal is primarily dorsal in indirect trauma with secondary displacement either medially or laterally.

Figure 2A and 2B Anteroposterior (A) and Lateral (B) radiograph showing reduction of first metatarsocuneiform dislocation after 2 years.

This is seen when the foot is planter flexed with weight borne by metatarsal heads, compressing the foot in longitudinal axis causing it to bow (hyper planter flexion) rupturing capsule and ligaments of tarsometatarsal joint resulting in dorsal dislocation. Also the strong structures of the sole of foot, such as the planter fascia and intrinsic muscles reinforce the planter surface of this joint and thus resist dorsiflexion of the metatarsals and planter dislocation of the tarsometatarsal joint. [7,8,9]

Dislocations due to direct trauma require tremendous force such as run over by a heavy object or struck by a falling weight. The metatarsals are displaced plantarward with secondary displacement medially or laterally, depending on the line of force. [7,8,9] In our case the falling weight had struck directly over the base of first metatarsal resulting in the planter dislocation at metatarsomedial cuneiform joint without any associated fracture.

Most studies recommend open reduction and fixation with screws or K wires [6,9,10,11] in complex fracture dislocations of tarsometatarsal joints. The important determinant of outcome in the treatment of injuries of tarsometatarsal joint is accurate anatomic reduction. [10] Our patient was managed conservatively by closed reduction achieving anatomic reduction, which was found stable and short leg cast with an uneventful recovery.

Conclusion

A high index of suspicion should be maintained to rule out tarsometatarsal joint injuries when examining a patient with an injured foot because delayed or missed diagnosis occurs in up to 20% of cases. [10] Left untreated, such disruption may result in marked disability characterized by painful posttraumatic arthritis and deformity [11] with the goal of treatment being restoration of pain free and a functional foot.

References

1. Charrois O, Begue T, Muller GP, Masquelet AC. Plantar dislocation of the tarso-metatarsal articulation (Lisfranc articulation). Apropos of a case. Rev Chir Orthop.1998; 84:197–201.
2. Mehara AK, Bhan S. Isolated fracture-dislocations of the first tarsometatarsal joint. J Trauma. 1992 Nov; 33(5):683-686.
3. Milankov M, Miljkovic N, Popovic N. Concomitant plantar tarsometatarsal (Lisfranc) and metatarsophalangeal joint dislocations. Arch Orthop Trauma Surg 2003; 123: 95–97.
4. Cuenca Espierrez J, Martinez AA, Herrera A, Panisello JJ. The floating metatarsal: first metatarsophalangeal joint dislocation with associated Lisfranc dislocation. J Foot Ankle Surg. 2003; 42(5):309–311.
5. Shetty MS, Pinto D, Bhardwaj P. Isolated floating first metatarsal: report of an unusual injury. J Foot Ankle Surg. 2007 May-Jun; 46(3):185-187.
6. García Mata S, Hidalgo Ovejero A, Martinez Grande M. Complete dorsal tarsometatarsal dislocation of the first metatarsal. Arch Orthop Trauma Surg 2003; 123: 95–97.
7. Wilson DW. Injuries of the tarsometatarsal joint: etiology, classification and results of treatment. JBJS1972; 64B:677–668.
8. Aitken AP, Poulson D. Dislocations of the tarsometatarsal joint. JBJS 1963; 45A: 246-260.
9. Arntz CT, Hansen ST jr. Dislocations and fracture dislocations of the tarsometatarsal joints. Orthop Clinics North America 1987; 18(1):105-114.
10. Gossens M, De Stoop n. Lisfranc’s fracture dislocations: etiology,radiology, and results of treatment. A review of 20 cases. Clin Orthop 1983;176:154-162.
11. Thompson MC, Mormino MA. Injury to the Tarsometatarsal Joint Complex.
J Am Acad Orthop Surg. 2003; 11:260-267.

Address correspondence to: Dr. Asif Sultan Government hospital for bone and Joint Surgery Barzullah, Srinagar India 190005.
Email ; drasifsultan@yahoo.com

1 Government hospital for bone and Joint Surgery Barzullah, SrinagarIndia 190005.
2 Resident Government Medical College Srinagar.

© The Foot and Ankle Online Journal, 2010

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Lateral Subtalar Dislocation of the Foot: A case report

Posted on December 1, 2008 | Comments Off on Lateral Subtalar Dislocation of the Foot: A case report

by J. Terrence Jose Jerome, MBBS, DNB (Ortho), MNAMS (Ortho)1 , Mathew Varghese, M.S. (Ortho)2 , Balu Sankaran, FRCS, FAMS3 , K. Thirumagal, MD4

The Foot & Ankle Journal 1 (12): 2

Subtalar dislocation is the simultaneous dislocation of the distal articulations of the talus at both the talocalcaneal and talonavicular joints. It can occur in any direction and always produce significant deformity. Most common is the medial dislocation. Less common presentations are lateral, anterior and posterior dislocations. These dislocations are associated with osteochondral fractures. Closed reduction and immobilization remains the mainstay of treatment. Radiographs and computed tomography scan confirms the post reduction alignment stability of subtalar joints and intra-articular fracture fragments. We report a case of lateral subtalar dislocation without osteochondral fracture fragments in a 30-year-old man.

Key words: Subtalar dislocation, dislocated talus, closed reduction, immobilization

This is an Open Access article distributed under the terms of the Creative Commons Attribution License.  It permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. ©The Foot & Ankle Journal (www.faoj.org)

Accepted: November, 2008
Published: December, 2008

ISSN 1941-6806
doi: 10.3827/faoj.2008.0112.0002

Subtalar dislocations are rarely found in routine orthopedic practice. Many of these dislocations result from high-energy injuries such as falls from a height, athletic injuries or a motor vehicle accident. [1] Inversion or eversion force is dissipated through the weak talonavicular and talocalcaneal ligaments, which eventually result in subtalar dislocation.

There are two types of subtalar dislocation. In lateral subtalar dislocation, the head of talus is found medially and the rest of the foot is dislocated laterally. In medial subtalar dislocation, the head of the talus is found laterally and the rest of the foot is dislocated medially.

Medial dislocation has been referred to as an “acquired clubfoot”, while the lateral injury is described as an “acquired flatfoot”. We present a case of an adult with lateral subtalar dislocation following a fall.

Case Report

A 30-year-old man who sustained a fall from the stairs came to our emergency department with pain and swelling of the right foot. The foot was diffusely swollen with minimal laceration and tenting of the skin over the prominent talar head which was felt medially. The rest of the foot was found dislocated laterally. (Figs. 1 and 2) Pulse of the posterior tibial and dorsalis pedis artery were not felt due to massive soft tissue distortion. Radiograph of the right foot showed lateral subtalar dislocation. (Figs. 3 and 4) Doppler ultrasound showed normal arterial flow in both posterior tibial and dorsal pedis arteries.

Figure 1   The foot was diffusely swollen with minimal laceration and tenting of the skin over the prominent talar head which was felt medially.

Figure 2   The right foot was found to be dislocated laterally.

Figure 3   The dorsoplantar view shows the dislocation of the talo-navicular and subtalar joints. Head of the talus was seen lying medially. Normal alignment of calcaneo-cuboid joint is appreciated.

Figure 4   The lateral view again shows the dislocation of the talo-navicular and subtalar joints. Head of the talus is severely declinated.

Closed reduction was done under spinal anesthesia. Firm manual foot traction with counter-traction on the leg combined with direct digital pressure over the head of talus aided in smooth reduction, which was associated with an audible clunk.

Post reduction radiographs showed normal and stable alignment of subtalar and talo-navicular joints without osteochondral fractures. (Figs. 5 and 6)

Figure 5   The post reduction anterior posterior radiograph showed normal and stable alignment of subtalar and talo-navicular joints without osteochondral fractures.

Figure 6   The post reduction lateral radiograph showed normal and stable alignment of subtalar and talo-navicular joints without osteochondral fractures.

Computer tomography (CT) scan confirmed the absence of osteochondral fractures and the stability of the subtalar joints. The patient was immobilized in a short-leg posterior plaster splint for 4 weeks. Following immobilization, the patient underwent a vigorous, active exercise program. The patient progressed to weight bearing and active range of motion exercises to regain subtalar and midtarsal joint motion. Two years after the injury, the patient had a stable, relatively good functional foot with minimal pain on walking on uneven ground.

Discussion

Subtalar dislocation by definition has a normal tibiotalar joint. Most dislocations occur in males (6:1) of early age. Subtalar dislocation can occur in any direction and always produce significant deformity.

Most commonly (80% to 85%), the foot is displaced medially with the calcaneus lying medially, the head of the talus prominent dorsolaterally, and the navicular medial and sometimes dorsal to the talar head and neck. [1,2,3] Less commonly (15% to 20%), lateral dislocation occurs.

Inversion of the foot results in a medial subtalar dislocation, while eversion produces a lateral dislocation. The strong calcaneonavicular ligament resists disruption, and the inversion or eversion force is dissipated through the weaker taloavicular and talocalcaneal ligaments. This disrupts these two joints which causes displacement of the calcaneus, navicular and all distal bones of the foot as a unit, either medially or laterally. [2,3]

The sustentaculum tali acts as a fulcrum about which the foot rotates to lever apart the talus and calcaneus in medial subtalar dislocation. The foot pivots about the anterior process of the calcaneus, again causing the talus and calcaneus to separate in lateral subtalar dislocation. [1,2,3,4]

Rare cases of anterior [5] and posterior [1] displacement of the foot after subtalar dislocation have also been reported. It is important to distinguish the medial or lateral subtalar dislocations because the method of reduction is different and the long-term prognosis appears to be worse with the lateral dislocation.

Between 10% and 40% of subtalar dislocations are open.6 Open injuries tend to occur more commonly with the lateral subtalar dislocation pattern and probably as the result of a more violent injury. [6] Long term follow-up demonstrated very poor results with the open subtalar dislocations.

The keystone of treatment for all subtalar dislocations is prompt and gentle reduction under general or spinal anesthesia. [7] All open injuries must be thoroughly debrided at the time of reduction, and the wound should be left open, with delayed primary closure anticipated in 3 to 5 days. Due to the high incidence of associated articular fracture and associate poor prognosis, CT scan of the foot and ankle should be obtained after reduction and splinting.

Simple dislocation that is reduced readily by closed reduction and do not have associated fracture, do very well. [1] In approximately 10% of medial subtalar dislocations and 15% to 20% of lateral dislocations, closed reduction cannot be achieved. [3,8] Soft tissue interposition and bony blocks have been identified as factors preventing closed reduction. Another common obstruction to closed reduction in medial dislocations is an impaction fracture of the articular surface of talus and navicluar. [7]

In comparison, the most common obstruction to closed reduction in lateral subtalar dislocation is the interposed tibialis posterior tendon. [8]

Open reduction is done for irreducible medial, lateral subtalar dislocations and osteochondral fracture fragments which blocks closed reduction. Any small, loose articular fracture fragments should be removed. Large intra-articular fractures should be reduced and fixed with Kirschner wires or small screws to restore joint stability and congruity. [9]

The only consistent complication in simple uncomplicated dislocations is limitation of subtalar joint motion, with the occasional associated symptoms of difficulty in walking on uneven ground and pain in the foot with weather changes. [2,7]

Lancaster and co-workers noted a poorer prognosis when there were associated injuries such as soft tissue injury, open contaminated injuries, extra-articular fracture, intra-articular fracture, infections, lateral subtalar dislocations, neglected subtalar dislocations and osteonecrosis. [10]

Our patient, who had sustained a fall from stairs, came with a diffusely swollen foot with the head of talus felt medially and the rest of the foot dislocated laterally as a unit. Radiographs confirmed the lateral subtalar dislocation. There was no associated osteochondral fracture. Simple closed reduction was successful. Our literature review showed few reports of isolated lateral subtalar dislocation.

We emphasize the importance of proper diagnosis and timely management of dislocations around the subtalar joint, as these tend to result in a significant deformity with joint stiffness. Lateral subtalar dislocation is one such type dislocation which is not mentioned in the literature and should be carefully treated. There should always be a high index of suspicion concerning associated osteochondral fractures. CT scan should be performed after reduction to assess for the intra-articular fractures of the subtalar joint. Open reduction is recommended for irreducible dislocations and fixation is recommended in large displaced, articular fractures that can produce subtalar joint incongruity.

References

1. DeLee JC, Curtis R. Subtalar dislocation of the foot. J Bone Joint Surg 64A: 433 – 437, 1982.
2. Grantham SA. Medial Subtalar dislocation: five cases with a common etiology. J Trauma 4 (11): 845 – 849, 1964.
3. Heppenstall RB, Farahvar H, Balderston R, Lotke P. Evaluation and management of subtalar dislocations. J Trauma 20 (6): 494 – 497, 1980.
4. Monson ST, Ryan JR. Subtalar dislocation. J Bone Joint Surg 63A (7): 1156 – 1158, 1981.
5. Inokuchi S, Hashimoto T, Usami N. Anterior subtalar dislocation: case report. J Orthop Trauma 11(3): 235 – 237, 1997.
6. Goldner JL, Poletti SC, Gates HS 3rd, Richardson WJ. Severe open subtalar dislocations: long-term results. J Bone Joint Surg 77A (7):1075 – 1079, 1995.
7. Bohay DR, Manoli A 2nd. Subtalar dislocations. Foot Ankle Int 16(12): 803 – 808, 1995.
8. Leitner B. Obstacles to reduction in subtalar dislocations. J Bone Joint Surg 36A (2): 299 – 306, 1954.
9. Naranja RA Jr, Monaghan BA, Okereke E, Williams GR Jr. Open medial subtalar dislocation associated with posterior process fracture of the talus. J Orthop Trauma 10(2): 142 – 144, 1996.
10. Lancaster S, Horowitz M, Alonso J. Subtalar dislocations: a prognosticating classification. Orthopedics 8 (10): 1234-1240, 1985.

Address correspondence to: Dr. J. Terrence Jose Jerome, MBBS.,DNB (Ortho), MNAMS (Ortho)
Registrar in Orthopedics, Dept. of Orthopedics
St. Stephen’s Hospital, Tiz Hazari, Delhi 54, India

1 Registrar in Orthopedics, Department of Orthopedics, St. Stephens Hospital, Tiz Hazari, Delhi, India.
2 Head Professor, Department of Orthopedics, St. Stephens Hospital, Tiz Hazari, Delhi, India.
3 Professor Emeritus, Orthopedics, St. Stephens Hospital, Tiz Hazari, Delhi, India. E-mail: pasle@bol.net.in
4 Professor , Orthopedics, Tamilu, India.

© The Foot & Ankle Journal, 2008

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