Tag Archives: open reduction

Intramedullary fixation of distal fibular fractures in a geriatric patient: A case report

Posted on September 30, 2018 | Comments Off on Intramedullary fixation of distal fibular fractures in a geriatric patient: A case report

by Amanda Kamery DPM1*, Craig Clifford DPM MHA FACFAS FACFAOM2

The Foot and Ankle Online Journal 11 (3): 1

Intramedullary rod fixation is presented as a viable treatment option for distal fibular fractures in the geriatric population. This technique leads to a reduction in wound complications, hardware irritation, procedure time and need for subsequent surgeries as seen with traditional open reduction internal fixation for distal fibular fractures in higher-risk patients.

Keywords: ankle fracture, trauma, geriatric, open reduction

ISSN 1941-6806
doi: 10.3827/faoj.2018.1103.0001

1 – Franciscan Foot and Ankle Institute- St Francis Hospital, Federal Way, WA PGY-3
2 – Residency Director, Franciscan Foot and Ankle Institute- St Francis Hospital, Federal Way, WA
* – Corresponding author: akamery@kent.edu

Geriatric patients are at an increased risk for sustaining ankle fractures due to increased fall rate and decreased bone density. Surgical repair for such injuries is often complex, due to the standard large incision and relatively bulky fixation which is necessary in the geriatric patient due to their generally poor bone stock [1]. This traditional form of fixation carries a complication rate of up to 30% [2]. Additionally, wound healing complications and hardware irritation is more common in this population due to a poor soft tissue envelope, with wound infection rates ranging from 26-40% [3]. Commonly, subsequent surgeries are necessary to remove hardware or to perform wound debridements [4]. As it is well documented that surgical morbidity increases in this population, it is important to utilize techniques and fixation methods that limit subsequent encounters. In this case report, we present intramedullary fixation for distal fibular fractures as a viable option for the geriatric population.

Case  Report

The patient is a 94-year-old male who presented 5 days after a fall with a Weber B, slightly comminuted, left distal fibular fracture (Figure 1a). Due to the unstable nature and slight displacement of the fracture, surgical intervention with an intramedullary fibular rod was chosen. Intra-operatively under general anesthesia, excellent anatomic reduction was noted after placement of the rod and one syndesmotic screw (Figure 1b).

At 2 weeks postoperatively, the posterior splint and skin staples were removed. The patient transitioned to protected heel touch weight-bearing for 4 weeks. He resumed regular activity and normal shoe wear at 6 weeks postoperatively. There were no wound healing complications or hardware irritation noted throughout the postoperative course. At 12 months follow up, patient reported no ankle pain or limitations in activities of daily living (Figures 2a-b).

 

Figure 1 AP ankle radiograph showing Weber B fracture with slight comminution and displacement (a). Two weeks postoperative AP radiograph showing excellent anatomic reduction with fibular rod and syndesmotic screw (b).

 

Figure 2 Twelve months post operative AP (a) and lateral (b) radiographs showing excellent bony consolidation of fracture fragments and adequate anatomic reduction.

Discussion

Treatment of distal fibular fractures in geriatric patients have an increased risk for postoperative complications which can lead to wound healing issues and subsequent surgeries. It is important to utilize techniques and fixation methods that limit subsequent encounters in order to decrease surgical morbidity in this cohort. The intramedullary fibular rod is an excellent alternative to traditional ORIF in the geriatric population. Our case example demonstrates an ideal patient for this technique, including successful anatomic realignment and uneventful postoperative course.

References

  1. Mitchell JJ, Bailey JR, Bozzio AE, Fader RR, Mauffrey C. Fixation of distal fibula fractures: an update. Foot Ankle Int. 2014;35(12):1367-1375.
  2. Lamontagne J, Blachut PA, Broekhuyse HM, O’Brien PJ, Meek RN. Surgical treatment of a displaced lateral malleolus fracture: the antiglide technique versus lateral plate fixation. J Orthop Trauma. 2002;16(7):498-502)
  3. Höiness P, Engebretsen L, Stromsoe K. The influence of perioperative soft tissue complications on the clinical outcome in surgically treated ankle fractures. Foot Ankle Int. 2001;22(8):642-648.
  4. Lee YS, Huang HL, Lo TY, Huang CR. Lateral fixation of AO type-B2 ankle fractures in the elderly: the Knowles pin versus the plate. Int Orthop 2007;31:817–821.

 

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A Complex midtarsal dislocation of the foot following a supination abduction injury: A case report

Posted on December 31, 2017 | Comments Off on A Complex midtarsal dislocation of the foot following a supination abduction injury: A case report

by Rajesh Kumar Chopra1, Narendran Pushpasekaran2*, Sathyamurthy Palanisamy2, Balu Ravi2

The Foot and Ankle Online Journal 10 (4): 5

Closed midfoot dislocations are not uncommon injuries. The key to good functional outcomes is stable concentric reduction by understanding the injury pattern and early intervention to maintain the biomechanics of the foot. We report on a 20-year-old male, the presentation of a complex pattern of closed traumatic dislocation of the midfoot, managed by open reduction and internal fixation with Kirschner wires for six weeks. He did not show any evidence of instability or arthritis and had a foot function index of 94% at 14 months. The unique presentation of this midfoot dislocation is the separation of naviculocuneiform and calcaneocuboid joints. An entity that requires reporting in literature as it remains unclassified and to add to the spectrum of injuries caused by the deforming forces of foot.

Keywords: foot injuries, tarsal bones, open reduction, arthritis, foot function index

ISSN 1941-6806
doi: 10.3827/faoj.2017.1004.0005

1 – M.S.(Ortho), professor, department of orthopaedics, vardhaman mahavir medical college and safdarjang hospital, new delhi, india.
2 – M.S.(Ortho), resident, department of orthopaedics, vardhaman mahavir medical college and safdarjang hospital, new delhi, india.
* – Corresponding author: drnaren247ortho@gmail.com

Closed traumatic dislocations of the midfoot are common injuries in level 1 and 2 trauma care [1]. Apart from the common Lisfranc, Chopart and talonavicular dislocations, swivel-type dislocations of the medial column involving the talus, navicular and cuneiforms, and lateral columns involving the calcaneus and cuboid bones have rarely been reported [2-4]. The proposed injury mechanisms to cause such injuries are dorsiflexion, plantar flexion, abduction and adduction forces or a combination of them [5]. However, involvement of both columns in the form of complete disruption of the naviculocuneiform and calcaneocuboid joints has been infrequently reported in the literature. We report this complex presentation sustained following a supination-abduction force.

Case report

A 20-year-old male, presented to the emergency department after a motor vehicle collision. He sustained a supination-abduction injury in a dorsiflexed foot and developed pain, deformity and swelling in the right foot. The forefoot was depressed and supinated in relation to the hindfoot with mild contusion and skin necrosis over the talonavicular prominence. An abnormal prominence was noted dorsally and medially at the naviculocuneiform joint. (Figures 1A and B). Distal pulses, toe movements and neurological examination were normal. There were no associated injuries in the body. The patient had no medical illness or neuropathies. Radiographs of the foot and ankle showed complete dislocation between the naviculo-cuneiform and calcaneocuboid joints with disruption of the calcaneo-navicular articulation. (Figures 2A and B). This pattern of injury has not been included in any classifications  available in literature.

Figure 1 showing the deformities-step at the naviculocuneiform  junction, forefoot supinated in relation to hindfoot. Pressure necrosis is seen over the navicular site.

Figure 2 Anteroposterior and Oblique views of right foot and ankle showing dislocation of the naviculocuneiform and calcaneocuboid joints (white arrow). Chip fracture of the navicular (black arrow), the site of attachment of calcaneonavicular ligament.

Under general anaesthesia, closed reductions were attempted with the knee flexed and the ankle in 15 degree plantar flexion. The deformity was initially exaggerated and reduction attempted by traction and manipulation opposite to the deforming forces. However, incongruent reduction required an open reduction through Ollier’s approach. The dorsal midtarsal ligament, lateral and plantar cuboideonavicular ligaments were found to be ruptured. Congruent stable reduction was achieved and secured with two 2mm Kirschner wires (K-wires) stabilizing the calcaneocuboid joint and two k wires fixating the medial two cuneiforms and the navicular under image intensifier control (Figures 3A and B). The ruptured ligaments were meticulously repaired. Additional immobilisation by below knee cast and non weight bearing was maintained for 6 weeks. With the removal of the K-wires, physiotherapy, partial weight bearing, medial arch support and controlled ankle motion boot were instituted. The patient had full weight bearing and a plantigrade foot at his 4 month follow-up. The patient had a mild restriction of subtalar motion and restriction of dorsiflexion by 5 degrees. He had no clinical or radiological signs of instability or arthritis and foot function index of 94% at 14 months (Figures 4A and B).

Figure 3 AP and oblique views of the foot and ankle. The navicular, the three cuneiforms and calcaneocuboid joints are concentrically reduced and fixed with K-wires.

Figure 4 Anteroposterior and oblique views of foot and ankle at 14 months follow-up showing normal alignment of arches and no arthritis.

Discussion

Closed midfoot dislocations are not uncommon presentations in level 1 or 2 trauma centers [1]. Apart from the common complex dislocations of Lisfranc and Chopart, isolated and swivel-type fractures and dislocations involving the medial column (talus, navicular and cuneiforms) and lateral column (calcaneus and cuboid) have rarely been reported [2-4]. However, the midfoot dislocations involving the separation of naviculocuneiform and calcaneocuboid joints are rare pattern of injuries infrequently reported in the literature (Table 1).

  Report Patient details Mode of injury Pattern Treatment Follow up Outcomes
1 Q. Choudry et al in 2007 [6]. 34/ male Fall of motorized palate over foot Naviculo- cuneiform subluxation and calcaneocuboid dislocation Closed reduction and immobilization for 6 weeks 15 weeks Good
2 y. chen et al in 2012 [7]. 64/ male Run over by car cuboid, medial and intermediate cuneiform fractures with naviculo-cuneiform and calcaneocuboid dislocation Open reduction and internal fixation of fractures 6 months Good
3 y. chen et al in 2012 [7]. 59/female Car accident left navicular, medial cuneiform and calcaneal fractures with calcaneal–cuboid, navicular–cuneiform and first tarsometatarsal joint dislocations Open reduction and internal fixation 3 months Chronic pain due to calcaneo cuboid instability
4 Our patient 20/male Fall from bike Isolated calcaneal–cuboid, navicular–cuneiform dislocation Open reduction and stabilization 14 months Good

Table 1 Review of reported naviculocuneiform and calcaneocuboid disruptions.

Main and Jowett had extensively studied the mechanisms of midtarsal injuries and proposed the various deforming forces causing the midtarsal fractures and dislocations [5] (Table 2).

Deforming forces Spectrum of midfoot injuries
1 Medial Fracture-sprains, fracture- subluxations or dislocations, swivel dislocations (talonavicular).
2 Longitudinal In plantar flexed foot- navicular fractures.

In dorsiflexed foot- talus fractures, dorsal navicular dislocations.
3 Lateral Fracture-sprains, fracture- subluxations or dislocations, swivel dislocations (talonavicular or naviculocuneiform with intact calcaneo-cuboid).
4 Plantar Fracture-sprains, fracture- subluxations or dislocations (chopart), plantar swivel dislocations.
5 Crush Fractures of mid tarsals.

Table 2 Mechanism of midfoot injuries [5].

Our case presents an unusual and complex pattern of injury in which plantar-abduction force at the midfoot caused the injury path through naviculocuneiform joint and calcaneocuboid joints causing complete dislocation of the three cuneiforms and cuboid articulations. This extends the spectrum of injury pattern caused by abduction deforming forces.

Obtaining concentric and stable reduction is of paramount importance to restore the biomechanics of the foot and prevent debilitating arthritis [8]. The management and prognosis of such complex midtarsal injuries in the literature have not been elaborated, except for a few case reports favoring open reduction and internal fixation [9]. In our case, the patient had good outcomes treated by open reduction and Kirschner wire fixation.

Conclusion

We report this case of traumatic closed dislocation of naviculocuneiform and calcaneocuboid joints following supination abduction deforming forces. Such injuries require further reporting to understand the spectrum of midfoot injuries. Congruent and stable fixation is of paramount importance to maintain proper biomechanics of foot.

References

  1. Hanlon DP. Leg, ankle, and foot injuries: Emerg Med Clin North Am 2010; 28(4):885-905.
  2. Davis CA, Lubowitz J, Thordarson DB. Midtarsal Fracture-Subluxation; Case Report and Review of the Literature: Clin Orthop Relat Res 1993; 292: 264-268.
  3. Dhillon MS, Nagi ON. Total dislocations of the navicular: are they ever isolated injuries?: J Bone Joint Surg [Br] 1999; 81:881-885.
  4. Kollmansberger A, De Boer P. Isolated calcaneocuboid dislocation: a brief report: JBJS [Br] 1970; 71:323-325.
  5. Main BJ, Jowett RL. Injuries of the midtarsal joint: JBJS [Br] 1975; 57:89–97.
  6. Choudry Q, Akhtar S, Kumar R. Calcaneocuboid and naviculocuneiform dislocation: An unusual pattern of injury: J Foot Ankle Surg 2007;13:48–50.
  7. Cheng Y, Yang H, Sun Z, Ni L, Zhang H. A Rare Midfoot Injury Pattern: Navicular–Cuneiform and Calcaneal– Cuboid Fracture–Dislocation: J Int Med Res 2012; 40(2):824-31.
  8. Richter M, Wippermann B, Krettek C, Schratt HE, Huefner T, Thermann H: Fractures and fracture dislocations of the midfoot: occurrence, causes and long-term results. Foot Ankle Int 2001; 22:392–8.
  9. 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; 25:340–8.

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Lateral subtalar dislocation: A case report

Posted on September 30, 2014 | Comments Off on Lateral subtalar dislocation: A case report

by Vijaykumar Kulambi1, Gaurav M2pdflrg

The Foot and Ankle Online Journal 7 (3): 4

Subtalar dislocation refers to the simultaneous dislocation of the distal articulations of the talus at the talocalcaneal and talonavicular joints. Closed reduction and immobilization remains the treatment of choice. However, if closed reduction is unsuccessful in some patients, open reduction is required. Open reduction can be associated with higher energy subtalar dislocations. 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 an open lateral subtalar dislocation that required open reduction.

Key words: Subtalar joint, dislocation, open reduction

ISSN 1941-6806
doi: 10.3827/faoj.2014.0703.0004

Address correspondence to: Dr. Gaurav M
E mail : movement.gaurav@gmail.com

1 Professor, Dept. of Orthopaedics, J.J.M. Medical College, Davangere, Karnataka State, India.
2 Post graduate student, Dept. of Orthopaedics, J.J.M. Medical College, Davangere, Karnataka State, India.

Subtalar dislocation is an uncommon injury accounting for 1-2% of all joint dislocations [1]. It involves the disruption of the talocalcaneal and talonavicular joints, while the calcaneocuboid joint remains intact [2,3,4,5]. Medial dislocations comprise up to 85% of subtalar dislocations, whereas lateral subtalar dislocations are less frequent occurring in 15% to 20% of dislocations. In medial subtalar dislocation, the head of the talus is found laterally and the rest of the foot is dislocated medially. However, in a lateral subtalar dislocation, the talus can remain fixed while the remaining structures of the foot are dislocated laterally along the talus. Subtalar dislocations present with an impressive amount of deformity. The medial dislocation has been referred to as an acquired clubfoot, while the lateral dislocation has previously been described as an acquired flatfoot [6]. Many of these injuries are open as well, particularly when associated with a high-energy mechanism. Up to 40% of subtalar dislocations may present with an open wound [7].

We present a unique case report of a 30 year old male patient presenting with an open lateral subtalar dislocation following a fall from a height, with posterior tibialis tendon interposition posing difficulty in closed reduction.

Case Report

A 30 year old male patient presented with a history of a fall from a height as he climbed a coconut tree. Initial examination revealed diffuse swelling of the left foot with a laceration of 4 cm over the medial aspect of the left foot, extending distally from below the medial malleolus. The left foot was fixed in a pronated position. Distal perfusion and neurological status of both lower limbs and bladder functions were intact.

Radiographs revealed dislocation of the left talocalcaneal and talonavicular joints, without any regional bony injury (Figure 1, 2, 3).

Initially, closed reduction was attempted which was unsuccessful. The patient was taken to the operating room for open reduction. The talus was explored through the medial wound, and the tendon of tibialis posterior was found to be interposed between the talus and calcaneum.

fig1

Figure 1 Preoperative lateral view, demonstrating subtalar joint dislocation without fracture.

fig2

Figure 2 Preoperative ankle AP view, demonstrating subtalar joint dislocation without fracture.

fig3

Figure 3 Preoperative oblique foot view, demonstrating talonavicular joint dislocation without fracture.

fig4

Figure 4 Postoperative lateral view, demonstrating Kirschner wire fixation.

The posterior tibial tendon was retracted, and the talus was levered into a more anatomical position with reduction achieved. Adequate reduction was confirmed using a computer assisted radio monitor (c-arm). A thick Kirschner wire was inserted from the calcaneum into the talus to hold the reduction (Figure 4). A below knee splint was applied after placing a sterile dressing on the operative site.

Discussion

Clinical reviews of subtalar dislocations are relatively infrequent and generally limited to a small numbers of patients. These injuries most commonly occur in young adult males, although Bibbo et al noted 36% of subtalar dislocations in their case series of 25 patients occurred in patients over 40 years of age [8].

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. Lateral subtalar dislocations are often associated with a higher energy mechanism and a worse long-term prognosis compared to medial subtalar dislocations.

Subtalar dislocations can result from either high-energy or low-energy mechanisms. The distinction is important because outcome has been correlated with the severity of the initial injury. In the case series presented by Bibbo et al, high-energy mechanisms such as motor vehicle trauma and falls from a height accounted for 68% of subtalar dislocations [8]. Open subtalar dislocations and lateral subtalar dislocations are more common with a high-energy mechanism. Medial injuries are more common than lateral dislocations, suggesting that the forces required to produce it are less than those required to produce a lateral dislocation.

High-energy subtalar dislocations may be associated with other injuries, either regional or involving other body systems. Bibbo et al described associated foot and ankle injuries in 88% of patients with subtalar dislocations. In their series of subtalar dislocations from a major level 1 trauma center, other musculoskeletal injuries occurred in 48% of patients and 12% of patients had injuries to the head, abdomen, or chest [8]. Regional fractures include talus, ankle, calcaneus, navicular, cuboid, cuneiform, and metatarsal fractures [9]. Osteochondral shearing injuries to the articular surface of the talus, the calcaneus, or the navicular are common. These injuries occur in up to 45% of patients, and are difficult to detect on plain radiographs [3,10,11]. Injuries remote from the foot and ankle may occur as well.

All subtalar dislocations require a timely reduction. In most cases, closed reduction can be accomplished. Often times, the injury presents with skin tenting requiring a prompt reduction to reduce the possibility of skin necrosis. Open peritalar dislocations require a formal irrigation and debridement in addition to the reduction followed by wound closure [12].

In approximately 10% of medial subtalar dislocations and 15% to 20% of lateral dislocations, closed reduction cannot be achieved [13,14]. Soft tissue interposition and bony blocks have been identified as factors preventing closed reduction. With medial dislocations, the talar head can become trapped by the capsule of the talonavicular joint, the extensor retinaculum, the extensor tendons, or the extensor digitorum brevis muscle [13,14]. With a lateral dislocation, the posterior tibial tendon may become firmly entrapped and present as a barrier to closed reduction requiring open reduction [14,15].

In our case presentation, the patient had sustained a high-energy trauma leading to a lateral subtalar dislocation. Following the initial failed closed reduction attempt, open reduction was required. We identified the tibialis posterior tendon obstructing the possible closed reduction. This case report shows successful open reduction of a lateral subtalar dislocation with Kirschner wire fixation.

References

  1. Perugia D, Basile A, Massoni C, Gumina S, Rossi F, Ferretti A. Conservative treatment of subtalar dislocations.  Int Orthop 2002;26(1):56-60. – Pubmed citation
  2. Plewes LW, McKelvey KG. Subtalar dislocation.  J Bone Joint Surg Am 1944 Jul;26(3):585-8. – Online
  3. DeeLee JC, Curtis R. Subtalar dislocation of the foot. J Bone Joint Surg Am 1982 Mar;64(3):433-7. – Pubmed citation
  4. Bohay DR, Manoli A II. Subtalar joint dislocations.  Foot Ankle Int 1995 Dec;16(12):803-8. – Pubmed citation
  5. Smith H. Subastragalar dislocation: a report of seven cases.  J Bone Joint Surg Am 1937 Apr;19(2):373-80. – Online
  6. Straus DC. Subtalar dislocation of the foot.  Am J Surg 1935;30:427-34.
  7. Merchan EC. Subtalar dislocations: Long-term follow-up of 39 cases.  Injury 1992;23(2):97-100. – Pubmed citation
  8. 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(2):158-63. – Pubmed citation
  9. Christensen SB, Lorentzen JE, Krogsoe O, Sneppen O. Subtalar dislocation.  Acta Orthop Scand 1977;48(6):707-11. – Pubmed citation
  10. Grantham SA. Medial subtalar dislocation: five cases with a common etiology.  J Trauma 1964 Nov;4:845-849. – Pubmed citation
  11. Heppenstall RB, Farahvar H, Balderston R, Lotke P. Evaluation and management of subtalar dislocations.  J Trauma 1980 Jun;20(6):494-7. – Pubmed citation
  12. Edmunds I, Elliott D, Nade S. Open subtalar dislocation.  Aust N Z J Surg 1991 Sep;61(9):681-6. – Pubmed citation
  13. Mulroy RD. The tibialis posterior tendon as an obstacle to reduction of a lateral anterior subtalar dislocation.  JBJS 1955 Jul;37-A(4):859-63. – Pubmed citation
  14. Leitner, B. Obstacles to reduction in subtalar dislocations.  JBJS 1954 Apr;36(A:2):299-306. – Pubmed citation
  15. Sanders DW. Fractures of the talus.  In: Bucholz RW, Heckman JD, Court-Brown C, editors.  Rockwood and Green’s Fractures in Adults.  Vol 1.  6th ed.  Philadelphia: Lippincott Williams & Wilkins; 2006.  2249-2292.

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