Subtalar Dislocation Research Articles

Classifications in Brief: The Hawkins Classification for Talus Fractures.

As reported by Coltart [5], Fabricius von Hilden first described talus injuries in 1608, and in 1919, Anderson et al. [1] reported a series of talus fracture dislocations in which they emphasized dorsiflexion as the mechanism of injury and coined the term ‘‘aviator’s astragalus’’ (astragalus being another term for talus) because of the impressive frequency with which the mechanism—aircraft accidents— was associated with the injury in question. In 1952, Coltart [5] reported on 228 talus injuries treated by surgeons in the British Royal Air Force in an attempt to describe the variety of injuries that occur to the talus and surrounding joints. He described various talus fracture patterns, fracture-dislocation combinations, and isolated peritalar dislocations [5]. Others have presented case series of talus injuries and associated rarely used classification schemes [15, 19], but all have noted high complication rates with injuries to the talus [5, 11, 15, 19]. In 1970, proposed treatment strategies for vertical fractures of the talar neck ranged from nonoperative management to urgent open reduction internal fixation, bone graft augmentation, fusion of the dorsal talus to the distal tibia, and even complete talectomy [11]. Although the importance of early, anatomic reduction of these injuries was noted at that time, the incidence of avascular necrosis (AVN) was not. In 1970 Hawkins [11] described injury patterns and AVN rates in a series of 57 vertical talar neck fractures in 55 patients from three different institutions. All 55 patients sustained forced dorsiflexion injuries, similar to the mechanism described by Anderson et al. [1] in pilots.

Subtalar Dislocation: Long-Term Follow-Up and CT-Morphology

Introduction: Although rare, subtalar dislocations are severe injuries with long-term alterations such as clinical dysfunction or painful posttraumatic arthritis. The objective of this study was to investigate long-term morphological changes of subtalar dislocations and to correlate them to clinical function. Based on the conclusions, suggestions for therapy guidelines were made in order to improve the functional outcome. Methods: Twenty-two patients (12 with a medial, 9 with a lateral and 1 with an anterior dislocation) were re-examined with an average follow-up time of 10 years. Radiological results of a computer tomography examination of the hindfoot were related to the clinical outcome, and both were discussed in the context of further parameters, such as additional injuries, time until reduction, and post-reduction treatment. Results: Additional injuries were found to affect the clinical outcome and/or the radiological changes. Predictive factors for limited range of motion were severe skin trauma and traumatic brain injuries. Factors that predicted both poor clinical function and clear signs of arthritis included complex talus, ankle and calcaneus fractures, long time until reduction, and infection. Conclusions: In many cases, radiological results can be correlated to clinical outcomes. However, the modulating effects of additional injuries should be considered when planning therapy. In cases with additional fractures of the talus and the calcaneus, suffering pain may be reduced by an early arthrodesis of the talo-cal-canear joint. In cases involving a long stay on an intensive care unit, early functional treatment by passive motion should be discussed in special cases to improve the clinical outcome.

Subtalar dislocations, Total Talar Dislocations and the Extruded Talus: A Polynymous injury or separate entities?

Subtalar dislocations, Total Talar Dislocations and the Extruded Talus: A Polynymous injury or separate entities?

Subtalar Dislocation Associated with a Ruptured Tibialis Posterior Tendon: A Rare Case Report

We report a case on a rare ankle injury which occurred after an opened trauma of the left ankle, associating a lateral subtalar dislocation with a ruptured tibialis posterior tendon. We treated him surgically with a good evolution clinic and radiological.

Rare case of pure medial subtalar dislocation: Conservative treatment and 32 months follow-up.

Rare case of pure medial subtalar dislocation: Conservative treatment and 32 months follow-up.

Unexpected Injury During Jumping Exercise

Objectives:The purpose of this case presentation is to report the results of physical therapy and conservative treatment of a rare clinical entity, isolated subtalar dislocation that occurred during triple jumping during which maximum compression forces act on the foot.Methods:A 20 years old national triple jumping athlete fell during daily sports exercises which consist of jumping to the medial and lateral side trying to catch a sports ball bouncing from the wall while his right foot was inverted and in plantar flexion. The patient was admitted to our emergency service. The physical examination revealed that the hindfoot was displaced medially. The neurological examination was intact and there was no sign of dermal injury. After the radiological examination the diagnosis was isolated subtalar dislocation. The dislocation was reduced with longitudinal traction with the knee was in flexion. The MR imaging did not reveal any chondral damage. The choice of treatment was conservative. After 4 days as the edema subsided, a short leg cast was applied for four weeks. Then, the cast was removed and active range of motion exercises were initiated. The first 25 days consisted of exercises with rubber band, bottle rolling under the foot. The second phase included walking in the pool and the patient was asked to start weight bearing partially. The patient went on with proprioception and strengthening exercises. Later, kinesiologic taping was also added to the therapy. He changed his jumping foot and started his routine training program with the team after 170 days. He participated in his first official competition 16 months after the injury. At the 28. month, he broke the national record in the National Interuniversities Athletics Games. 2 months later, he got the third place in the World Athletics Championship.Results:The follow up period was 4 years. AOFAS score was 76 at second month and 83 at the fourth. At the first and at the fourth year, AOFAS score was 100. No dermal lesions or joint stiffness or signs of arthritis was observed. Avascular necrosis of talus or complex regional pain syndrome was not encountered.Conclusion:Early return to sports activities is of tantamount importance as early reduction. Reduction can be carried out in an open or closed manner. For prevention of joint stiffness, immobilization period has to be short and active ROM exercises has to be initiated with partial weight bearing as soon as the joint stability and strength is adequate.

Reconstructions after inveterated fractures and dislocations of the foot

Inveterated fractures or dislocations of the foot which are defined as being more than 6-12 weeks old can be secondarily reconstructed anatomically in only very rare cases. All other cases need reorientation of all axes of the foot requiring single or combined joint fusion. In cases of significant posttraumatic bone necrosis the dead bone has to be radically resected and substituted by an autogenous bone graft from the iliac crest. Old cases of dislocation, for example after subtalar dislocation without anatomical reduction, need reorientation of the foot axes by performing arthrodesis. Subluxation of the medial Lisfranc joint after an unrecognized rupture of Lisfranc ligament can be controlled later by anatomical repair of this ligament by using half of the extensor digitorum longus tendon and thus avoiding arthrodesis.

Biomechanical evaluation of two commonly used external fixators in the treatment of open subtalar dislocation—A finite element analysis

Subtalar dislocation is a rare injury caused by high-energy trauma. Current treatment strategies include leg casts, internal fixation and external fixation. Among these, external fixators are the most commonly used as this method is believed to provide better stabilization. However, the biomechanical stability provided by these fixators has not been demonstrated. This biomechanical study compares two commonly used external fixators, i.e. Mitkovic and Delta. CT imaging data were used to reconstruct three-dimensional models of the tibia, fibula, talus, calcaneus, navicular, cuboid, three cuneiforms and five metatarsal bones. The 3D models of the bones and cartilages were then converted into four-noded linear tetrahedral elements, whilst the ligaments were modelled with linear spring elements. Bones and cartilage were idealized as homogeneous, isotropic and linear. To simulate loading during walking, axial loading (70N during the swing and 350N during the stance phase) was applied at the end of diaphyseal tibia. The results demonstrate that the Mitkovic fixator produced greater displacement (peak 3.0mm and 15.6mm) compared to the Delta fixator (peak 0.8mm and 3.9mm), in both the swing and stance phase, respectively. This study demonstrates that the Delta external fixator provides superior stability over the Mitkovic fixator. The Delta fixator may be more effective in treating subtalar dislocation.

Missed peritalar injuries: an analysis of factors in cases of known delayed diagnosis and methods for improving identification.

Because of the complex anatomy of the foot, rarity of fractures of the foot, and subtle radiographic cues, foot injuries are commonly overlooked and mis/undiagnosed. This study seeks to investigate a patient population whose peritalar injuries, including fractures and dislocations, were missed on initial examination, in order to analyze factors of known, missed injuries and provide insight into methods for reducing the incidence of missed diagnoses. Surgical cases between January 1999 and May 2011 were queried and retrospectively reviewed to identify missed peritalar injuries. Of 1682 surgical cases reviewed, 27 patients with missed peritalar injury(ies), which were subsequently confirmed by imaging studies, were identified. Using the Orthopaedic Trauma Association classification, fracture and dislocation subtypes were classified. A medical record review was performed to assess demographic and surgical data elements. In this study population, 7 types of peritalar injuries (talus, calcaneal, navicular, and cuboid fractures as well as subtalar, calcaneocuboid, and talonavicular joint dislocations) were diagnosed in 27 patients. All patients required surgical intervention. Talus fractures were the most commonly missed injury. In patients with multiple peritalar injuries, there was a strong correlation between talus and navicular fractures (r = -0.60; P < .01) as well as a moderate correlation between talus fractures and calcaneocuboid dislocations (r = -0.46; P = .02). The presence of a calcaneal fracture significantly decreased the time to definitive diagnosis (P = .01). Male patients' diagnoses were delayed an average of 324 days and females 105 days (P = .04). A moderate correlation was found between patient age at injury and time to diagnosis (r = -0.47; P = .04), with a decreased time to diagnosis as patient age increased. Significant factors were identified in this patient population, including patient sex and age, which may contribute to missed or delayed diagnosis in the clinical setting. Prompt and accurate diagnosis of peritalar injuries may improve long-term outcomes. Care Management, Level V.

A new look at the Hawkins classification for talar neck fractures: which features of injury and treatment are predictive of osteonecrosis?

Osteonecrosis and posttraumatic arthritis are common after talar neck fracture. We hypothesized that delay of definitive fixation would not increase the rate of osteonecrosis, but that the amount of initial fracture displacement, including subtalar and/or tibiotalar dislocations, would be predictive. We investigated the possibility of dividing the Hawkins type-II classification into subluxated (type-IIA) and dislocated (type-IIB) subtalar joint subtypes. The cases of eighty patients with eighty-one talar neck and/or body fractures who had a mean age of 36.7 years were reviewed. The fractures included two Hawkins type-I, forty-four type-II (twenty-one type-IIA and twenty-three type-IIB), thirty-two type-III, and three type-IV fractures. Open fractures occurred in twenty-four patients (30%). One deep infection, two nonunions, and two malunions occurred. After a mean of thirty months of follow-up, sixteen of sixty-five fractures developed osteonecrosis, but 44% of them revascularized without collapse. Osteonecrosis never occurred in fractures without subtalar dislocation (Hawkins type I and IIA), but 25% of Hawkins type-IIB patterns developed osteonecrosis (p = 0.03), and 41% of Hawkins type-III fractures developed osteonecrosis (p = 0.004). Osteonecrosis occurred after 30% of open fractures versus 21% of closed fractures (p = 0.55). Forty-six fractures were treated with urgent open reduction and internal fixation (ORIF) at a mean of 10.1 hours, primarily for open fractures or irreducible dislocations. With the numbers studied, the timing of reduction was not related to the development of osteonecrosis. Thirty-five patients had delayed ORIF (mean, 10.6 days), including ten with Hawkins type-IIB and ten with Hawkins type-III fractures initially reduced by closed methods, and one (5%) of the twenty developed osteonecrosis. Thirty-five patients (54%) developed posttraumatic arthritis, including 83% of those with an associated talar body fracture (p < 0.0001) and 59% of those with Hawkins type-III injuries (p < 0.01). Following talar neck fracture, osteonecrosis of the talar body is associated with the amount of the initial fracture displacement, and separating Hawkins type-II fractures into those without (type IIA) and those with (type-IIB) subtalar dislocation helps to predict the development of osteonecrosis as in this series. It never occurred when the subtalar joint was not dislocated. When it does develop, osteonecrosis often revascularizes without talar dome collapse. Delaying reduction and definitive internal fixation does not increase the risk of developing osteonecrosis.

Rekonstruktionsmaßnahmen nach veralteten Frakturen und Luxationen des Fußes

Inveterated fractures or dislocations of the foot which are defined as being more than 6-12 weeks old can be secondarily reconstructed anatomically in only very rare cases. All other cases need reorientation of all axes of the foot requiring single or combined joint fusion. In cases of significant posttraumatic bone necrosis the dead bone has to be radically resected and substituted by an autogenous bone graft from the iliac crest. Old cases of dislocation, for example after subtalar dislocation without anatomical reduction, need reorientation of the foot axes by performing arthrodesis. Subluxation of the medial Lisfranc joint after an unrecognized rupture of Lisfranc ligament can be controlled later by anatomical repair of this ligament by using half of the extensor digitorum longus tendon and thus avoiding arthrodesis.

Isolated Subtalar Dislocation

EDUCATIONAL OBJECTIVES As a result of reading this article, physicians should be able to: 1. Understand the etiology, epidemiology, and importance of treatment of isolated subtalar dislocation. 2. Understand the most common management practices when treating isolated subtalar dislocation and identify variations in management that may affect prognosis. 3. Consolidate reported patient outcomes as they pertain to variations in management strategies to explore which practices may provide the best prognosis after treatment of isolated subtalar dislocation. 4. Highlight the importance of further study to determine the best course of management for isolated subtalar dislocation regarding variables in treatment. This study reviews the literature on isolated subtalar dislocation published within the past 5 years. Variation in management existed mostly in the categories of treatment choice, immobilizer type, and period of immobilization, with closed reduction, closed reduction and percutaneous pinning, below-knee casting, less than 4 weeks of immobilization, and 6 weeks of immobilization reporting good results. The good results described after the addition of percutaneous K-wire fixation to the initial treatment method of isolated subtalar dislocation, immobilization via below-knee casting, and shorter periods of immobilization suggest that these practices may be useful for the treatment of this rare injury.

Spontaneous peri-talar dislocation after steroid intra-articular injections: A case report

We report a case of spontaneous peri-talar dislocation after intra-articular steroid injections. We have reviewed the literature on spontaneous peri- and sub-talar dislocations and the effects of intra-articular steroid injections.

Conservative treatment of closed subtalar dislocation: A case report and 2 years follow-up

We report a case of a closed subtalar dislocation without any related fractures treated with closed reduction and conservative treatment with a cast immobilization. Pure subtalar dislocation without any fractures is extremely rare and hardly reported in the literature. Such injuries are more likely to be open and associated with fractures of the surrounding foot bones such as malleoli, talus or fifth metatarsal fractures. In the examined case, closed reduction was followed by cast immobilization for 3 weeks. Six months post-injury, the patient had a full range of motion without any pain while there were no signs of residual instability or early post-traumatic osteoarthritis. Subjective clinical testing using a valid health instrument revealed an excellent outcome. We discuss in details the mechanism of such an injury and highlight the importance of prompt closed reduction and early mobilization to ensure a satisfactory long term outcome.

Correlation of AO and Lauge-Hansen Classification Systems for Ankle Fractures to the Mechanism of Injury

Our aim was to assess whether the Lauge-Hansen (LH) and the Muller AO classification systems for ankle fractures radiographically correlate with in vivo injuries based on observed mechanism of injury. Videos of potential study candidates were reviewed on YouTube.com. Individuals were recruited for participation if the video could be classified by injury mechanism with a high likelihood of sustaining an ankle fracture. Corresponding injury radiographs were obtained. Injury mechanism was classified using the LH system as supination/external rotation (SER), supination/adduction (SAD), pronation/external rotation (PER), or pronation/abduction (PAB). Corresponding radiographs were classified by the LH system and the AO system. Thirty injury videos with their corresponding radiographs were collected. Of the video clips reviewed, 16 had SAD mechanisms and 14 had PER mechanisms. There were 26 ankle fractures, 3 nonfractures, and 1 subtalar dislocation. Twelve fractures with SAD mechanisms had corresponding SAD fracture patterns. Five PER mechanisms had PER fracture patterns. Eight PER mechanisms had SER fracture patterns and 1 had SAD fracture pattern. When the AO classification was used, all 12 SAD type injuries had a 44A type fracture, whereas the 14 PER injuries resulted in nine 44B fractures, two 44C fractures, and three 43A fractures. When injury video clips of ankle fractures were matched to their corresponding radiographs, the LH system was 65% (17/26) consistent in predicting fracture patterns from the deforming injury mechanism. When the AO classification system was used, consistency was 81% (21/26). The AO classification, despite its development as a purely radiographic system, correlated with in vivo injuries, as based on observed mechanism of injury, more closely than did the LH system. Level IV, case series.

Bilateral Subtalar Dislocation in Gymnast: A Case Report

Subtalar dislocation is a rare injury in elite athletes. We report an unusual case of simultaneous bilateral subtalar dislocation in an international female athlete competing in gymnastics. These injuries require prompt reduction and immediate immobilisation in a plaster cast for 8 weeks or wire stabilisation after open reduction if an abrupt end to a promising career is to be prevented.

İzole Medial Subtalar Joint Dislocation: Case Report and Literature Review

İzole Medial Subtalar Joint Dislocation: Case Report and Literature Review

In reply: Hawkins's classification of the lateral process fractures of the talus: A letter to the Editor

We report a case of spontaneous peri-talar dislocation after intra-articular steroid injections. We have reviewed the literature on spontaneous peri- and sub-talar dislocations and the effects of intra-articular steroid injections.

Medial subtalar dislocation associated with fracture of the posterior process of the talus

A 17-year-old male sustained a medial subtalar fracture dislocation while playing basketball. The dislocation of the subtalar joint was reduced by closed means, but a large, comminuted, displaced posterior process fracture remained. Open reduction and internal fixation through a posteromedial approach was used to restore congruity to the subtalar joint. MRI at 12 months after injury showed no signs of avascular necrosis in the talus.

Konservatif tedavi edilen izole medial subtalar çıkık olgusunun orta dönem fonksiyonel sonuçları

Medial subtalar dislocations are rare injuries. A 35 year old male patient with medial subtalar dislocation was treated with closed reduction without anesthesia and below knee cast fixation for four weeks. At the end of the four year follow up the ankle-hind foot score was 100 according to American Orthopedic Foot and Ankle Society clinical rating system.