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Temporary bridge plating of the medial column in Chopart and Lisfranc injuries

Posted on March 31, 2017 | Comments Off on Temporary bridge plating of the medial column in Chopart and Lisfranc injuries

by Alaa Mansour DPM1*, Lawrence Fallat DPM, FACFAS2✛

The Foot and Ankle Online Journal 10 (1): 5

Severe traumatic injuries isolated to the midfoot region involving combined fracture and dislocation of the Chopart and Lisfranc joints are unique and uncommon. In the incidence of crush injuries and comminution with subsequent medial column shortening, maintaining anatomic reduction with rigid stabilization may pose a challenge to the surgeon. Bridge plating is generally used to maintain length, alignment and stabilize comminuted fractures by spanning across unaffected bones or joints, leaving the fracture area undisturbed. This technique reduces devitalization of fragments and promotes a healing environment. Temporary bridge plating  over violated joints serves to maintain reduction and relative congruence. A case is presented of a 25-year-old male with a dislocated and comminuted navicular and Lisfranc fracture following a motorcyle accident.

Keywords foot trauma, fracture dislocation, locking plate, medial column shortening, midfoot crush injury, navicular dislocation

ISSN 1941-6806
doi: 10.3827/faoj.2017.1001.0005

1 – Resident, Beaumont Hospital – Wayne, Wayne, MI
2 – Program Director, Podiatric Surgical Residency Program, Beaumont Hospital – Wayne, Wayne, MI
* – Corresponding author: alaa.mansour3@gmail.com
✛ – Conflict of interest: Consultant to Depuy-Synthes

Crush injuries to the midfoot are uncommon accounting for 6% of traumatic midfoot injuries, with midtarsal joint (Chopart) fracture-dislocations being the most severe [1-4]. In a review of 155 patients, 72% of midfoot injuries were caused by traffic accidents with 52% and 17% caused by car and motorcycle accidents, respectively [2]. Simultaneous fractures occur in approximately 75-90% of Chopart fractures, with only 10-25% percent of injuries being purely ligamentous [4, 5]. These injuries generally occur with high-energy trauma and are at an increased risk for soft tissue compromise and compartment syndrome. This may lead to long-term morbidity and functional impairment if misdiagnosed and not properly treated.

Midfoot injuries typically result in multiple intra-articular tarsal fractures with the failure of key supporting structures, such as bony articulations and ligamentous attachments. When structures in the joint complex begin to fail, increased stress is transferred to the surrounding joints leading to subsequent loss of joint function. Failure of the talonavicular joint (TNJ) leads to flattening of the longitudinal arch, abduction of the forefoot, and a gradual valgus deformity of the subtalar joint resulting in a painful flatfoot [6].

Pinney and Sangeorzan classified fractures of the navicular body into three types. In type I, the fracture line is transverse in the coronal plane with a dorsal fragment. In type II, the fracture line passes from dorsolateral to plantarmedial with the large fragment being dorsomedial. In type III, navicular fractures are comminuted and often result in medial disruption at the naviculocuneiform joint (NCJ) with lateral displacement of the foot and subluxation of the lateral column [7].

Comminuted fracture dislocations of the navicular and cuboid, in particular, can result in medial and lateral column shortening presenting a challenge for the surgeon to restore the length and congruity of the joint. Typically, the treatment of choice for comminuted fractures involves stabilizing techniques such as bridge plating and external fixation. However, comminuted fractures specific to the midfoot have also been addressed through a variety of methods including closed reduction with crossing Kirschner-wire (k-wire) fixation, open reduction with k-wire or screw fixation, primary arthrodesis, external fixation and temporary bridge plating. Of these fixation types, bridge plates are advantageous because they allow the surgeon to maintain the length of the bones while also stabilizing the bony fragments too small for individual fixation. Bridge plating functions as an internal splint by providing fixation to both the proximal and distal intact bone creating a “bridge” over the site of comminution. The use of temporary bridge plating has been discussed in the literature as an alternative to external fixation to span comminuted fractures without extensive periosteal stripping or vascular compromise [8,9].  After healing is complete, the bridge plate is removed to restore joint motion.

Case Report

A 25-year-old male presented to the emergency department after crashing his motorcycle while intoxicated into a cement barrier traveling at a speed of 40-50mph. On physical examination, neurovascular status was intact and there were no open wounds or signs of compartment syndrome. Initial radiographs revealed a comminuted and dorsally dislocated navicular fracture along with significant disruption of the Lisfranc and midtarsal joint (Figure 1). Further detail was visualized in the computerized tomography scan (CT) revealing multiple fractures, which included a Type III intra-articular, comminuted, navicular fracture with a Chopart dislocation, a comminuted cuboid fracture, a Lisfranc dislocation, cuneiform fractures, and fractures of metatarsal bases two, three and four (Figure 2). Additionally, medial and lateral column shortening was evident with subsequent disruption of the talonavicular, calcaneocuboid (CCJ), and Lisfranc joints. Closed reduction was attempted in the Emergency room but was unsuccessful. He also sustained a nasal and left femur fracture.

Figure 1A Lateral view reveals dorsally dislocated and comminuted navicular fracture.

Figure 1B Anterior-Posterior [AP] view reveals comminution of the navicular, cuboid, Lisfranc fracture dislocation, and shortening of the medial column.

Figure 2A CT sagittal view of the comminuted and displaced cuboid fracture.

Figure 2B Coronal CT image depicting comminution of the navicular

The patient initially underwent open reduction and internal fixation of his femur by an orthopedic surgeon. One week later he was taken back to the operating room with the primary goal of reducing the navicular bone, restoring the length of the medial and lateral column, as well as reducing and fixating the Lisfranc dislocation of metatarsals 2, 3, and 4. The patient was placed on the operating table in the supine position and a pneumatic ankle tourniquet was inflated to 225 mmHg for hemostasis.

Prior to the incision, the area overlying the dislocated navicular was marked with a metallic marker under fluoroscopy. The dorsally displaced navicular fragment was then successfully reduced in a closed fashion with distraction of the foot in a dorsiflexed-inverted position. In order to appropriately restore the length of the medial column, it was deemed necessary to perform open reduction with internal fixation. A linear longitudinal incision was made dorsomedial to the TNJ and was carried distally past the first metatarsal cuneiform joint. Dissection revealed a large hematoma and rupture of the joint capsule above the TNJ and NCJ.  The navicular was severely comminuted and the fracture fragments were rotated such that the articular surface was pointing away from the joint surfaces of the talus and cuneiforms. The large fracture fragments were then reduced into correct anatomic orientation, but the degree of comminution still yielded an unstable medial column. To span the area of comminution and stabilize the medial column, the bridge plate technique was used.  The fracture fragments were temporarily stabilized with 0.062 inch K-wires and a 4.5mm cortical lag screw was inserted from dorsal to plantar in the center of the navicular fragment to maintain reduction and prevent dorsal displacement of the main body. A 12-hole plate was then temporarily fixated with olive wires and applied to the medial column spanning the talus, navicular and medial cuneiform (Figure 3). A total of ten 3.5mm fully-threaded locking screws were placed into the plate.

Figure 3A AP view after open reduction and internal fixation of the medial and lateral column utilizing a bridge plate, Lisfranc trans-articular screws, and a lateral column positional “bridge screw”.

Figure 3B Lateral view reveals restoration of the longitudinal arch with reduction and stabilization of the previously dislocated navicular fracture.

Closed reduction was performed with percutaneous fixation of the Lisfranc dislocation of metatarsals two, three and four using two 4.5 mm cannulated cortical screws. The first screw was oriented from the lateral aspect of the third metatarsal base into the second cuneiform, and a second screw was oriented from the lateral aspect of the fourth metatarsal base into the third cuneiform (Figure 3).

To maintain reduction and prevent shortening of the lateral column, a 5.5 mm fully-threaded cannulated “bridge screw” was inserted percutaneously into the lateral aspect of the base of the fifth metatarsal, through the center of the cuboid to end in the anterior calcaneus (Figure 3). The purpose of this screw was not to provide compression but simply to maintain the position and length of the lateral column by bridging the comminuted cuboid.

Post-operatively, the patient was placed into a well-padded posterior splint to accommodate for swelling that typically occurs after a traumatic injury such as this. The patient was instructed to be non-weight bearing on the affected extremity with the assistance of a walker.

After two weeks the patient returned for his first follow-up visit. The patient rated his pain as 2/10 and well controlled with oral pain medication. At this time, the patient opted for a Controlled Ankle Movement (CAM) boot instead of a cast due to his uninsured status. The patient was instructed to remain non-weight bearing and to keep the CAM boot on at all times.

At the six-week follow-up, the patient had disregarded our instructions and started weight bearing with the CAM boot. The patient presented to our clinic complaining of sharp heel pain both medially and laterally only while ambulating. The patient refused to have radiographs taken due to the cost. The patient was then lost to follow-up for some time.

At the four-month follow-up, the patient returned to the clinic stating that he stopped wearing the CAM boot after the last visit and returned to full-weight bearing. Fifteen weeks postoperatively, he presented to the emergency department secondary to pain in his foot. Radiographs revealed osseous union of all fracture sites with no displacement. However, the positional screw in the lateral column, as well as two additional screws within the medial column bridge plate were noted to be broken.

The patient underwent removal of hardware five months after the date of the original surgery. Intra-operatively, the navicular, and the medial and lateral columns were noted to be consolidated and in a rectus position with an intact medial longitudinal arch. Post-operatively, after the hardware removal, the patient was placed in a below-knee cast. After missing several appointments, the patient followed up one-month later stating that he removed his own cast with a hacksaw three days after surgery. The patient was placed into a CAM boot and instructed to decrease activity for two weeks before transitioning into regular shoe gear. Eight weeks after the hardware removal, the patient was back in regular shoe gear and denied any pain. One year from the original injury, the patient was satisfied with the outcome and was pain-free without any activity limitations.

Discussion

Midfoot injuries are uncommon because the corresponding joints contain strong ligamentous structures that are typically resistant to disruption. When these ligaments are disrupted or when fractures occur, dislocations may result to both the medial and lateral column, which may result in instability and shortening of the medial longitudinal arch or lateral column [10]. Consequently, shortening of the medial column can result in pes cavus while shortening of the lateral column can result in pes planus [10]. Main and Jowett determined that outcomes following midfoot injuries are dependent on the stability of the medial column [4]. The outcome for crush injuries in their study was only fair in 75% of cases following open or closed reduction with plaster cast immobilization [4].

Most of the crush injuries involving the navicular tend to be intra-articular at both the proximal and distal aspects because of the narrow anatomic shape of the bone [7]. Despite anatomic reduction, a satisfactory outcome may be hindered by cartilage damage caused by the intra-articular fracture. Pinney and Sangeorzan recommend restoration of at least 60% of the articular surface of the TNJ to prevent subluxation following fracture healing [7].

Temporary bridge plating allows for relative fracture-site stability despite severe comminution and thus has many advantages. It supports indirect healing and allows for adequate reduction without having to reduce and fixate each individual fragment. Bridge plates also restore length and alignment by spanning across unaffected bones, thus leaving the fracture area undisturbed. It also preserves the soft tissue attachments and blood supply by limiting extensive dissection needed for adequate exposure.  In this case presentation, the plate was used to successfully bridge the medial column from the talar neck to the first metatarsal. The cuboid was also stabilized with a positional screw to restore the length of the lateral column.  Schildhauer, et al., utilized a bridge plate in seven patients to span medial column injuries. All seven cases went on to heal and maintain proper length and alignment of the medial column [8].

On the other hand, bridge plating across joints, especially in the midfoot, restricts motion significantly. Astion, et al., has shown that arthrodesis of the TNJ has shown to dramatically decrease joint motion at the subtalar and calcaneocuboid joints [11]. Therefore, it is important to remove the plate and restore motion at the TNJ after the fracture is healed. Schildhauer, et al., recommend removal of the plate after 4-9 months to restore function to the TNJ and STJ [8].

A possible complication with bridge plating as with any treatment of severe fractures is wound dehiscence. Open reduction and internal fixation should be delayed in the presence of extensive swelling or soft tissue compromise. Excessive soft tissue dissection and exposure of fracture fragments should be limited because the soft tissue structures are the vascular envelope responsible for nurturing and promoting the healing of the injury. In a recent study, van Koperen, et al., indicates that one of the drawbacks of bridge plating is extensive dissection during plate placement and removal, which can increase the risk of wound complications. However, in their study bridge plating did not lead to more wound complications when compared with trans-articular fixation [12]. Atraumatic technique and understanding of surgical anatomy are important to prevent devascularization and limit post-surgical complications.

Another complication with comminuted fractures is avascular necrosis. Sarrafian describes the blood supply to the navicular as being radial in its arrangement, with the central body being relatively avascular [13]. Sangeorzan, et al., found that after open reduction and internal fixation of displaced navicular body fractures, six out of twenty-one [29%] patients developed radiographic signs of avascular necrosis, however, only one lead to collapse [14].  With appropriate fixation and understanding of the limitations of bridge plating, one can avoid complications such as non-union and avascular necrosis.

Temporary bridge plating is a viable treatment option for comminuted midfoot fractures that span joints without extensive dissection or vascular compromise.  It allows for relative fracture-site stability despite severe comminution and supports indirect healing without having to reduce and fixate each individual fragment. Bridge plates also restore length and alignment by spanning across unaffected bones, thus leaving the fracture area undisturbed. Overall, a good outcome was achieved using the bridge plate even with our patient bearing weight early, he was satisfied with the outcomes and returned to his previous activity level.

References

  1. Didomenico LA, Thomas ZM. Midfoot crush injuries. Clin Podiatr Med Surg. 2014;31(4):493-508.
  2. Richter M, Wippermann B, Krettek C, Schratt HE, Hufner T, Therman H. Fractures and fracture dislocations of the midfoot: occurrence, causes and long-term results. Foot Ankle Int. 2001;22(5):392-8.
  3. Makwana NK, van Liefland MR. Injuries of the midfoot. Current Orthopaedics 19:231-242, 2005.
  4. Main BJ, Jowett RL. Injuries of the midtarsal joint. J Bone Joint Surg Br 57:89-97, 1975.
  5. Richter M, Thermann H, Huefner T, Schmidt U, Goesling T, Krettek C. Chopart joint fracture-dislocation: initial open reduction provides better outcome than closed reduction. Foot Ankle Int. 2004;25(5):340-8.
  6. Sammarco, VJ. The talonavicular and calcaneocuboid joint: Anatomy, biomechanics, and clinical management of the transverse tarsal joint. Foot Ankle Clin. 9:127-45, 2004.
  7. Pinney SJ, Sangeorzan BJ. Fractures of the tarsal bones. Orthop Clin North Am. 2001;32(1):21-33.
  8. Schildhauer TA, Nork SE, Sangeorzan BJ. Temporary bridge plating of the medial column in severe midfoot injuries. J Orthop Trauma. 17:513-520, 2003.
  9. Cammack PM, Donahue MP, Manoli A. The bridge and barrel hoop plates as alternatives to external fixation techniques in the foot and ankle. Foot Ankle Clin. 2004;9(3):625-36, xi.
  10. Dhillon MS, Nagi ON. Total dislocations of the navicular: are they ever isolated injuries? J Bone Joint Surg Br. 81:881-885, 1999.
  11. Astion DJ, Deland JT, Otis JC, Kenneally S. Motion of the hindfoot after simulated arthrodesis. J Bone Joint Surg Am. 1997;79(2):241-6.
  12. Van koperen PJ, De jong VM, Luitse JS, Schepers T. Functional outcomes after temporary bridging with locking plates in Lisfranc injuries. J Foot Ankle Surg. 2016;55(5):922-6.
  13. Sarrafian SK. Anatomy of the Foot and Ankle, pp 340-342, JB Lippincott, Philadelphia, 1983.
  14. Sangeorzan BJ, Benirschke SK, Mosca V, Mayo KA, Hansen ST. Displaced intra-articular fractures of the tarsal navicular. J Bone Joint Surg Am. 1989;71(10):1504-10.

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Posterior dislocation of the subtalar joint: A case report

Posted on August 31, 2016 | Comments Off on Posterior dislocation of the subtalar joint: A case report

by Vijay Kumar Kulambi, MBBS, MS (ORTHO)1, Deepak. A, MBBS, (D. ORTHO)2*pdflrg

The Foot and Ankle Online Journal 9 (3): 2

Dislocation of the talocalcaneonavicular or subtalar joint is a rare occurrence. Posterior subtalar dislocations are even rarer among subtalar dislocations. The injury is characterized by a simultaneous dislocation of talocalcaneal and talonavicular joints while tibiotalar and calcaneocuboid articulations remain intact. Although many of these dislocations result from a high-energy injury, such as a fall from a height or RTA, a significant number of these injuries occur as a result of athletic injuries. Closed reduction and immobilization remains the treatment of choice. Early anatomical reduction is the key to preventing long term complications such as midtarsal joint arthritis and faulty foot mechanics.  However, if closed reduction is unsuccessful in some patients, open reduction is required. A variety of bone and soft tissue structures may become entrapped, resulting in obstruction of closed reduction. This is a unique case report which presents an unsuccessful closed reduction of a closed posterior subtalar dislocation that required open reduction.

Key words: subtalar joint dislocation, foot trauma, STJ, joint dislocation

ISSN 1941-6806
doi: 10.3827/faoj.2016.0903.0002

1 – Professor of Department of Orthopaedics. JJM Medical College, Davangere, Karnataka State, India 577004.
2 – Postgraduate student, Dept. of Orthopaedics, J.J.M. Medical College, Davangere, Karnataka State, India 577004.
* – Corresponding author: deepus_7891@yahoo.co.in / deepus.7891@gmail.com

Subtalar joint (STJ) dislocation is a rare injury of the foot and ankle with most reported cases occurring after major trauma. The rarity of this injury can be attributed to the presence of strong ligament connecting the talus and the calcaneus, the strong biomechanical properties of the ankle and the tight joint capsule. When a dislocation occurs to this joint, it is considered a serious injury due to the instability that can occur across Chopart’s joint [1].

Main and Jowett described this dislocation type injury occurring at the midtarsal joints with a classification system to help the physician decide the best course of treatment (Table 1) [2].

The dislocation results in substantial distortion of the foot shape. Fractures of the fifth metatarsal, the talus, anterior process of calcaneus and the malleoli are often a result of with subtalar dislocations [3]. Subtalar dislocations without associated fracture are rare because of the inherent instability of these types of injuries (the talus has two articular surfaces which contribute in the formation of talonavicular and talocalcaneal joints) [4].

It has also been demonstrated that injury in this area can easily dislocate the subtalar joint. In most of the cases the calcaneus and the rest foot is dislocated medially. Dislocation can be reduced spontaneously [5].

The purpose of this study is to report a rare case of a posterior subtalar dislocation with associated fractures in which closed reduction failed, and ultimately open reduction and internal fixation was done. We also describe the mechanical patterns resulting in subtalar dislocation, s-pitfalls that arise during closed reduction, choosing the right patient for open reduction.

Case Report

A 48 years old male presented with a history of one day old injury to right ankle following an accidental fall by slipping on a slope, with the right foot being forced mainly into hyperplantar flexion and eversion. He presented with complaints of pain, swelling, deformity just distal to the ankle and proximal foot, and was unable to bear weight on right foot.

Table 1 Main and Jowett classification for midtarsal joint injuries [2].

Clinical examination showed the foot being fixed in plantar flexion, mild eversion with diffuse swelling and tenderness in midfoot and proximal 3rd shaft of right fibula region without any type of external wound. A prominent rounded bony prominence was palpated at the talonavicular articulation, suggestive of talonavicular dislocation with palpable talar head. Skin over the dorsum was stretched and edematous. All movement (passive and active) of the right ankle was painful and restricted completely. There was no distal neurovascular deficit. The plain radiographs of right ankle and right leg in AP and lateral views showed posterior talonavicular dislocation with a very mild lateral displacement in the right foot with fracture of anterior process of the right calcaneum and plain radiographs of leg showed fracture of proximal 1/3rd shaft of right fibula (Figures 1 and 2). Initial closed reduction under spinal anaesthesia failed and thus resulting in open reduction with a dorsolateral approach. The talus was explored through a dorsolateral incision and the tendon of tibialis anterior was found to be interposed between the talus and calcaneus. The head of the talus was impacted onto the navicular bone, hindering the attempt for closed reduction.  Tibialis anterior tendon was retracted and talar head had to be levered back into anatomical position after opening the talonavicular joint capsule (Figure 3). The reduction was confirmed under C – arm (Figure 4) and then a thick Kirschner wire was inserted from the calcaneus into the talus to hold the reduction (Figure 5). A below knee splint was applied after placing a sterile dressing at the operative site.

Figure 1 Subtalar dislocation, fibula fracture.

Figure 2 Preoperative x- rays of the patient injured foot.

    

Figure 3 Intraoperative pictures from left to right;  i) tibialis anterior tendon interposing between the talar head; ii) tendon retracted and joint capsule opened exposing the talar head; iii) talar being lever back into anatomical position; iv) post reduction of subtalar joint; v) K – wire fixation post reduction of subtalar joint.

 

Figure 4 Intraoperative images showing talonavicular joint i) pre reduction, ii) post reduction.

 

Figure 5 Intraoperative images showing stabilisation of the talonavicular joint using K-wires.

Discussion
Subtalar joint dislocations were first described in 1811 and have also be referred to as peritalar or subastragalar [6,7]. A more accurate term for subtalar joint dislocations would be talocalcaneal navicular (TCN) dislocations.

The most widely used classification has been described by Broca in 1852 [5], who distinguished 3 types of subtalar dislocation (Table 2): (1) the medial dislocation; (2) the lateral; and (3) the posterior dislocation. Direction of the rest foot in relation to the talus was the determinant element to classify dislocation as medial, lateral or posterior [5]. Subtalar dislocations are rare accounting for approximately 1% of all dislocations; 85% are medial dislocations with the other 15% accounting for lateral and the very rare anterior and posterior dislocations [9].
The incidence of posterior dislocation which was first described by Luxembourg in 1907 and it ranges from 0.8% to 2.5% of all TCN dislocations in different studies [3,4]. Posterior dislocation occurs when forces applied on the dorsum of the foot result in forceful extreme plantar flexion of the forefoot. It is hypothesized that pure hyperplantar flexion could lead to a progressive subtalar ligament weakening that may result in a complete ligament rupture if the plantar flexion force is prolonged [3]. This excessive hyperplantar flexion is normally the result of either a fall from a height or direct blunt force and trauma.

Direction of Dislocation Frequency of Dislocation
Medial 65-80%
Lateral 15-35%
Posterior 0.8-2.5%
Anterior 1%

Table 2 Broca and Malgaigne’s classification of talocalcaneal navicular joint dislocation with frequency [16].

This could be observed in the presence of good bone quality and if the force is applied distally at the navicular bone. The interosseous ligament and medial and lateral ligaments of the ankle joint are torn [9]. Generally there is no rotational component to posterior displacements of the TCN joint. The instances of posterior dislocations with rotational components were open injuries [10].

The diagnosis of posterior TCN dislocation can be confirmed with lateral and anteroposterior radiographs (Figure 3). On lateral radiographs, the head of the talus is atop the navicular, and the posterior portion of the talus will be in contact with the posterior subtalar facet of the calcaneus [11]. According to Inokuchi et al, the frontal view should show no significant medial-lateral displacement or rotation of the foot [3].

Immediate reduction under general or spinal anesthesia is recommended to avoid soft tissue complications and reduce the chances of avascular necrosis of the talus. Posterior dislocations are also very unstable due to the fact that the talus is balancing on two points, the navicular and the facets of the calcaneus, respectively. With posterior TCN dislocation, reduction can be achieved with no fixation by manual traction [9]. A radiograph should be performed to ensure the reduction of the dislocation and to exclude any iatrogenic fracture.

Associated fractures as cited in the literature include, talar neck and body fractures, anterior process of the calcaneus, posterior process of the talus, posterior malleolus chip fractures of the navicular, cuboid fractures, and associated osteochondral fractures [3,4,10,12]. A recent case report by Budd et al, showed that a posterior displacement was irreducible due to an anterior process fragment [12].

In general posterior dislocations do not require internal or external fixation. Fixation of associated fractures is required depending on the type of fracture, displacement, and timing of the injury. In general posterior dislocations do not require internal or external fixation. Fixation of associated fractures is required depending on the type of fracture, displacement, and timing of the injury. Good functional outcomes for closed posterior TCN dislocation have been uniformly reported in the literature [3]. Post-reduction immobilization in a non-weight bearing cast is required for TCN dislocation. In general we follow the protocol set forth by Jungbluth et al in 2010, consisting of six weeks in a short-leg cast with aggressive rehabilitation and full weight bearing thereafter [12]. Radiographs at 6-8 weeks are a usual protocol to ensure no vascular necrosis of the talus. This can also be done with the use of CT and MRI.

Most commonly, subtalar dislocation is an injury resulting from high energy trauma and, more frequently, it involves active young men. Between 10% and 40% of subtalar dislocations are open [7]. 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 dislocation [7].

The duration of immobilization remains controversial. Lasanianos et al [13] suggested that for uncomplicated medial subtalar dislocations, if passive and active range of motion exercises and partial weight bearing are started earlier, the outcomes regarding functionality are better when compared to those of longer immobilization periods [14].
In our case presentation, the patient had sustained a high-energy trauma leading to a posterior subtalar dislocation. Following the initial failed closed reduction attempt under spinal anaesthesia and hence open reduction was required. We identified the tibialis anterior tendon and the impaction of the talar head on the navicular bone obstructing the possible closed reduction. This case report shows successful open reduction of a posterior subtalar dislocation with Kirschner wire fixation.

References

  1. Powell E, LaBella M. Swivel-type Dislocation of the Talonavicular Joint: A case report. The Foot and Ankle Online Journal 2011:4(6):3
  2. Main BJ, Jowett RL. Injuries of the midtarsal joint. JBJS 1975 57B: 89-97
  3. Inokuchi S, Hashimoto T, Usami N. Posterior subtalar dislocation. J Trauma 1997; 42: 310-313
  4. Krishnan KM, Sinha AK. True posterior dislocation of subtalar joint: a case report. J Foot Ankle Surg 2003; 42: 363-365
  5. Zimmer TJ, Johnson KA. Subtalar dislocations. Clin Orthop Relat Res 1989; (238): 190-194
  6. Delee JC, Curtis R. Subtalar dislocation of the foot. J Bone Joint Surg Am 1982;64:433-7
  7. Goldner JL, Poletti SC, Gates HS, et al. Severe open subtalar dislocations. J Bone Joint Surg Am 1995;77-:1075-9
  8. Perugia D, Basile A, Massoni C, Gumina S, Rossi F, Ferretti A. Conservative treatment of subtalar dislocations. Int Orthop 2002;26(1):56-60.
  9. William Yoder, DPM, Patrick Nelson, DPM, Michael Bowen, DPM, Stephen Frania, DPM. Talocalcaneal navicular Dislocation: A review.
  10. Camarda L, Martorana U, D-Arienzo M. Posterior subtalar dislocation. Orthopedics: Case Report. July 2009;32.
  11. Pua U. Subtalar dislocation: rare and often forgotten. In J Emerg Med 2009;2:51-2.
  12. Jungbluth P, Wild M, Hakimi M, et al. Isolated subtalar dislocation. J Bone Joint Surg 2010;92:890-4.
  13. Lasanianos NG, Lyras DN, Mouzopoulos G, Tsutseos N, Garnavos C. Early mobilization after uncomplicated medial subtalar dislocation provides successful functional results. J Orthop Traumatol 2011; 12:37-43
  14. Giannoulis D, Papadopoulos DV, Lykissas MG, Koulouvaris P, Gkiatas I, Mavrodontidis A. Subtalar dislocation without associated fractures: Case report and review of literature. World J Orthop. 2015;6(3):374-9.

 

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