Informed consent was obtained from the patients who participated in this study. Talus fractures are significant because of their potential for long-term morbidity and complications. Can. Fractures of talar posterior process have three types, namely an isolated fracture of either medial or lateral tubercle and a simultaneous fracture of medial and lateral tubercles (i.e. Nonsurgical Treatment Many posterior malleolus fractures are small and do not require surgery. PubMed Central entire posterior process fractures). Disclaimer, National Library of Medicine Diagnosis of medial tubercle fractures of the talar posterior process using oblique views. If you find something abusive or that does not comply with our terms or guidelines please flag it as inappropriate. HHS Vulnerability Disclosure, Help 2015 May-Jun;35(3):765-79. doi: 10.1148/rg.2015140156. In one case series, 17 of 20 patients with fractures were . An official website of the United States government. PubMed Trauma 21, 579582. Orthopaedic Specialists of North Carolina. If a fracture wassuspected with plain radiographs, then an urgent CT scan wasrecommended in order to identify the fracture and assess the size and fracture fragment. Abdelgaid, S. M. & Ezzat, F. F. Percutaneous reduction and screw fixation of fracture neck talus. All CT scans were performed using a 256-slice Siemens CT scan (GE, United States) with 1.0mm slices at 0.1s intervals for the foot and ankle imaging. 51, 326329. Another limitation is the validity and reliability of the AOFAS and VAS score system, which is not universally examined and accepted. Initial assessment of short-term results in patients who underwent internal fixation using ORIF and percutaneous screw techniques for posterior talar process fracture was performed in this study. Cadaver specimen with posterior ankle joint and posterior talar process. The goal is to have the bones heal as closely to perfect as possible so as to prevent any residual instability or malalignment of the bone. (A) Flexor hallucis longus tendon; (B) posterior tibial artery; (C) plantar nerve. Appropriate, expedient treatment provides the patient the best chance of obtaining a good functional outcome. The cause of injury for eight of the cases was vehicle accident and for four of the cases sport injury. The mechanism of injury may result from a posteromedial facet impaction17. Foot Ankle Surg. Orthop. MeSH doi: 10.1016/j.cpm.2012.01.005. As the bone remains aligned after the blow, it is usually easier to treat a non-displaced fracture as compared to a displaced fracture. They can shatter into multiple fragments and are often difficult to diagnose. The ankle joint is a complex junction of three bones known as the fibula, tibia, and talus. Invest. There are only a few reports about cases of entire posterior process fractures, according to previous literatures6,18. Knowledge of the exact fracture fragment and safe zone of fracture fixation can help reduce the risk of joint penetration and neurovascular bundle damage. The small fragments were fixed using Kirschner wire and 3.0mm headless cannulated screws were used to fix the minimal displacement of fracture fragment or comminuted fracture. Once the posterior tibial neurovascular bundle and the flexor hallucis longus tendon were identified, they were retracted medially to achieve excellent exposure of the medial tubercle, lateral tubercle and FHL tendon groove (Fig. Well, the back of your ankle is the posterior aspect of your ankle, and the back of the talus is where the posterior process is. Kopp L, Obruba P, Riegl J, Meluzinov P, Edelmann K. Acta Chir Orthop Traumatol Cech. Journal of Orthopaedic Trauma. Before To view a copy of this licence, visit http://creativecommons.org/licenses/by/4.0/. Recognizing the influence of the anatomic region on the accuracy of assessing the screw position preoperatively can help the surgeon avoid placing screws that penetrate the articular facet or injuring the neurovascular bundle and tendon, as described in previous literature8,15. Description. This approach is especially suitable for patients who have multiple comorbidities and a higher perioperative risk. the posterior and the lateral. Pan Afr Med J. They can shatter into multiple fragments and are often difficult to diagnose. This technique offered a good evaluation of the fixation for talar process fractures preoperatively. Sports Med. Scientific Reports (Sci Rep) - inversion of ankle may avulse tubercle leaving PTFL intact; Use the Previous and Next buttons to navigate three slides at a time, or the slide dot buttons at the end to jump three slides at a time. The posterior talofibular ligament attaches to the lateral tubercle and flexor hallucis longus runs between these two tubercles. Simulation of inserting the virtual computer-aided design (CAD) screw (diameter 3.0mm) was performed, after obtaining three-dimensional (3D) reconstructions of original CT scans. and JavaScript. https://doi.org/10.1097/00005131-199602000-00014 (1996). Orthopaed. The talar avulsion fracture in this patient is also small with only slight displacement and is seen hovering just above the mid to anterior talus. Towson, MD 21204 CT scan provides more accuracy for assessment of size, displacement, and comminution fragment of posterior talar process fracture or lateral process of the talus than plain radiographs24. 19, 255258. Article EFORT Open Rev. 6 Hospital, Ningbo, Zhejiang, China, The Medical School of Ningbo University, Ningbo, Zhejiang, China, Department of Orthopaedic Surgery, Ningbo No. Injury 38, 13131317. Twelve cases were treated with these two techniques with satisfying clinical results overall. Differential diagnosis Firstly, deviation may be present in the results due to the nature of the research being retrospective and most importantly due to the limited number of cases. The talus is sandwiched in between these two, and you can see its sitting there squished right in between the tibia and the heel bone. [Surgical management of talus fractures: mid-term functional and radiographic outcomes]. The site is secure. A significant difference (p<0.05) was detected between AOFAS and VAS scores in the two groups preoperatively and postoperatively (Tables 3, 4). Letonoff, E. J., Najarian, C. B. Instead, surgery should be performed if the posterior malleolus fracture causes any instability of the ankle joint, irrespective of the size or location of the fracture.. Treatment of posterior ankle pain by excision of a bipartite talar fragment, Fractures of the Distal Tibial Metaphysis, Orthopaedic Specialists of North Carolina. Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations. By submitting a comment you agree to abide by our Terms and Community Guidelines. Long-term radiographic and clinical-functional outcomes of isolated, displaced, closed talar neck and body fractures treated by ORIF: the timing of surgical management. The AOFAS scores were categorized as excellent (90100 points), good (8089points), fair (7079 points), and poor (69 points)13. Trauma 32, 601606. Initial treatment of posterior impingement . Symptoms get worse with exercise, particularly running, and ease with rest. Fractures of the anterior process account for approximately 15 percent of all calcaneal fractures and are commonly misdiagnosed as ankle sprains. The incision is located at the middle line between the Achilles tendon and the medial border of the medial malleolus19. & Grenier, J. M. Fracture of the lateral tubercle of the posterior talar process caused by a rock-climbing fall: a case report. Today on the Doc On The Run Podcast were talking about posterior process fractures of the talus. This project was supported by the medical and health science and technology project of Zhejiang Province (2015KYB339) and Ningbo Natural Science Foundation (2018A610266). . All cases in this study were diagnosed based on CT scans, in which the fracture line and displacement were assessed for surgical protocol design. 2017;31(4):e116-e120. TIBIAL STRESS FRACTURE Reza Maulana Abstrak. 3). A posterior talar process fracture is a significant foot injury that can lead to a long road to recovery. Ebraheim, N. A. et al. A talus fracture is a condition characterized by a break in one of the small bones of the ankle, known as the talus (figure 1). Wijers, O., Engelmann, E. W. M., Posthuma, J. J., Halm, J. Talus Fracture (other than neck) Talus fractures (other than neck) are rare fractures of the talus that comprise of talar body fractures, lateral process fractures, posterior process fractures, and talar head fractures. Clinical outcome and concomitant injuries in operatively treated fractures of the lateral process of the talus. Liu, Z., Zhao, Q. The neck has approximately 15 to 20 of medial deviation and is the area most vulnerable to fractures. Average follow-up was 26 months (range: 18-43). Another way to do this is to go through dorsiflexion with a posterior glide on the talus. Excision of ununited fractures of the posterior process of the talus: a treatment for chronic posterior ankle pain. Intraoperative photo of ORIF. The methodological improvement in this study was a good option depending upon the size and displacement of the fracture fragment. The treatment recommended for small (<1 cm) and minimally displaced (<2 mm) fractures of the posterior process of the talus is conservative . Conservative Treatment of Posterior Malleolus Fracture Usually, conservative treatment of posterior malleolus fracture, is recommended for less severe and uncomplicated injuries. Ebraheim, N. A., Patil, V., Frisch, N. C. & Liu, X. https://doi.org/10.1038/s41598-020-77151-6, DOI: https://doi.org/10.1038/s41598-020-77151-6. From January 2008 to December 2010, 18 patients with displaced fracture of talar poste. Cedell, C. A. Rupture of the posterior talotibial ligament with the avulsion of a bone fragment from the talus. S92.101A initial encounter for closed fracture; S92 . So sometimes a posterior process is an actual fracture, and sometimes it's a natural occurrence where the bone just hasn't fully ossified, and technically you have this other thing called an Os trigonum it doesn't really matter the specifics of the terms or what that means, it just means you have a natural separation of the two pieces . Percutaneous screw fixation has also demonstrated success in certain patterns. FOIA The talus is situated below the tibia and fibula (lower leg bones) and connects with these . There was no significant difference for AOFAS scores and VAS scores between the two techniques (p>0.05). Blanchette, M. A. volume10, Articlenumber:20221 (2020) J. The posterior talar process fracture is an uncommon fracture and is frequently undiagnosed by orthopaedic surgeons. and J.Z. He founded Orthopaedic Specialists of North Carolina in 2001 and practices at Franklin Regional Medical Center and Duke Raleigh Hospital. 110 West Rd., Suite 227 Google Scholar. J. Pediatr. Talus fractures have a wide variety of presentation from low-energy avulsion fractures of the lateral or posterior processes, to high-energy comminuted talar body fractures. A shift>2mm indicated significant displacement with surgical treatment. 1,2,3,4,5,6,7,8,9,10,11,12,13,14,15,16,17 In a . All cases showed no screw loosening, implant breakage, nonunion, or malunion. Would you like email updates of new search results? In some cases, the bone will not need to be repositioned, and the fragment can be secured without surgery. Watch on. Podiatry Today. https://doi.org/10.1053/j.jfas.2016.02.001 (2017). Cedell fracture: Posterior talar process fracture with injury to the posteromedial tubercle caused by forced dorsiflexion and pronation. 5). Fractures of the talus: a comprehensive review. 2015;20:123. doi:10.11604/pamj.2015.20.123.6046, Duan X, Kadakia AR. Medicine 97, e13331. In our study, anatomical observation and classification of the posterior process of the talus were carried out, and related imaging and finite element methods were combined. The AOFAS and VAS scores were used to analyze the treatment outcomes. - look for tenderness and perhaps a mass just posterior to medial malleolus and pain w/ motion ofgreat toe (due to motion ofFHL); - surgical excision of the ununited fragment thru a posterolateral ankle arthrotomy may relieve the pain. Among a total of 12 patients have undergone pre and post-operative 3D-CT. Provided by the Springer Nature SharedIt content-sharing initiative, Journal of Orthopaedic Surgery and Research (2022). Treatment for a talus fracture depends on the type of fracture and the severity of your injury. This typically involves the separation of the posterior tibial insertion of the PCL to variable degrees. A lateral talus fracture (snowboarders fracture) occurs when your ankle is forced outward while a stress fracture to the Talus bone is a less common type of talus fracture, that usually occurs due to repetitive impact. Diagnosing and Treating Posterior Malleolus Fractures. Symptoms of a stress fracture of the talus develop gradually over time and include: Pain on the outside of the ankle. Entire posterior process fractures are easier to identify than isolated medial or lateral tubercle fractures on plain radiographs. Defination: a pott's fracture is a type of ankle fracture that is characterized by a break in one or more bony prominences on the sides of the ankle known as the malleoli . You can break your talus in a trauma like a fall or car accident. Because an isolated fracture of this sort is so rare, diagnoses are sometimes missed or inconclusive. Use of a 30-Degree External Rotation View for Posteromedial Tubercle Fractures of the Talus. 28400 - Closed treatment of calcaneal fracture. B 21, 439442. Foot Ankle Int. https://doi.org/10.1177/107110079801900414 (1998). . Non-billable ICD-10 code for fracture of posterior process of talus, use codes with a higher level of specificity: S92.131, S92.131A, S92.131B, S92.131D, S92.13. Talar dome injuries occur equally in men and women. 226230 (1994). Fracture of the posterior process of the talus is an uncommon injury that is often missed on plain X-Ray and misdiagnosed as ankle sprain. CAS Well that thing curves right down around the back of the ankle, and if you get a fracture or a crack in that part of the talus, when you roll your ankle really, really badly, well that can cause chronic pain, because what happens is that you get a little crack there, and every time you take a step, youve got the FHL tendon (flexor hallucis longus) going right around here and it wraps around as it goes down around the bottom of your foot, and every time you take a step and you pull down with the big toe, it actually pulls on the posterior process fracture and it moves it and that causes pain. Talus fracture treatment algorithm . This is why postoperative care will often require the ankle to be non-weight-bearing for six weeks. Created for people with ongoing healthcare needs but benefits everyone. - Frx of Lateral Tubercle of Posterior Process (Sheppard's Frx): Int J Surg Case Rep. 2017;41:360-365. doi:10.1016/j.ijscr.2017.10.062. The usual mechanism of injury is forced hyperplantarflexion and inversion causing direct compression of the posterior talus, or an avulsion fracture caused by the posterior talofibular ligament. Jonathan Cluett, MD, is board-certified in orthopedic surgery. Amoretti, N. & Huwart, L. Percutaneous screw fixation of a talar fracture under computed tomography and fluoroscopy guidance. Romeo, N. M., Hirschfeld, A. G., Githens, M., Benirschke, S. K. & Firoozabadi, R. Significance of lateral process fractures associated with talar neck and body fractures. & Yi, X. Posteromedial approach in treatment of talar posterior process fractures. The posterior talar process fractures present in the study were classified as lateral tubercle fracture, medial tubercle fracture and entire posterior process fracture. Fractures of talar posterior processes are prone to be misdiagnosed with primary plain radiographs (i.e. 2008 Sep;29(9):956-8. doi: 10.3113/FAI.2008.0956. And I give lectures at medical conferences about subtle fracture patterns, Ive been doing that for about 10 years or so, lecturing at medical conferences on this topic, because I did some research on another rare fracture called a Lateral Process Fracture, and in that study we actually looked at all of these patients that came into the hospitals and clinics over a three-year period, and what we found is that if a posterior process fracture was noticed on the x-ray, there was actually a statistical probability that you would also have a Lateral Process Fracture. Well, she asked me, What exactly is a posterior process fracture? Well, all right, Ill show you. Addressing posterior malleolar ankle fractures. PubMedGoogle Scholar. 9 Hospital, Ningbo, Zhejiang, China, You can also search for this author in 2). Some fractures involve both bones; others affect only one. Unable to load your collection due to an error, Unable to load your delegates due to an error. Cannulated screws are recommended for fracture fixation with small fracture fragments and articular cartridge. The yellow arrow is a cannulated screw. Intraoperative fluoroscopy photo of percutaneous screw implanted with the minimally invasive technique. If the symptoms persist; an additional period of immobilization (4 to 6 weeks) might be required. Your healthcare provider may recommend: Casting. Further, a trial of cast immobilization of acute posterior or lateral talar process fractures of at least 6 weeks is useful, . - posterolateral ankle tenderness may be elicited; The authors declare no competing interests. In total 35 cases of posterior talus fractures have been reported. 58, 286290 (2014). One or two 3.0mm cannulated screws were applied as a lag screw function (Fig. S92.1 Fracture of talus. Less serious injuries may. Surgery is the definitive treatment, indicated especially for open or displaced fractures. Watanabe, H., Majima, T., Takahashi, K., Kawaji, H. & Takai, S. Split fracture of the posteromedial tubercle of the talus: case report and proposed classification system. pott's fracture. The skin and subcutaneous tissue were carefully dissected when close to the posterior tibial neurovascular bundle (Fig. Traditionally, surgeons have long recommended surgery if more than 25% of the malleoli is involved. J. Surg. The https:// ensures that you are connecting to the https://doi.org/10.1016/j.injury.2007.04.025 (2007). BMJ Case Rep. 2013, 16:2012007763. - frx may also occur when ankle is forced into extreme equinus; 14 As expected, there seems to be a trend of increased complication rates with a longer follow-up . also known as broken ankle , ankle fracture and malleoli fracture . Swelling was a factor to the time of surgery. Talus mobilization for ankle mobility. de Palma, L., Santucci, A., Marinelli, M., Borgogno, E. & Catalani, A. PubMed Treatment may involve wearing a short leg cast or a removable brace. From January 2014 to December 2018, 12 cases with displaced fracture of talar posterior process were treated in our department. These medical reviewers confirm the content is thorough and accurate, reflecting the latest evidence-based research. Treatment relies on appropriate diagnosis, which hinges on clinical suspicion provided by the patient's account of pathomechanics, clinical examination, and radiological workup. Wu JQ, Ma SH, Liu S, Qin CH, Jin D, Yu B. Orthop Surg. Subsequently, the effectiveness of the surgical techniques and approaches for posterior process fractures is still controversial. The unfused ossification center of the lateral tubercle forms the os trigonum. The talus is shaped like a truncated cone and is wider anteriorly than posteriorly,which creates greater ankle stability in dorsiflexion. To the authors knowledge, there are few descriptions of surgical techniques for fractures of posterior talar process in the literature8,13,19. This is commonly referred to as a trimalleolar fracture in which all three bone structures are broken. Surgery was performed under general or epidural anesthesia and the patient was placed in prone position, with a well-padded tourniquet placed at the proximal thigh. The body includes the dome of the talus, which articulates with the ankle joint above. Safe Zone of Posterior Screw Insertion for Talar Neck Fractures on 3-Dimensional Reconstruction Model. BMJ Case Rep. 2013 . Statistical analysis was performed using the Statistical Package for Social Sciences (SPSS, IBM) version 20.0. 2017 Feb;9(1):28-33. doi: 10.1111/os.12303. To the authors knowledge, there is no literature on which treatment is a better option between ORIF and percutaneous screw for posterior talar process fracture. 7). TREATMENT 35. First, you'll be placed in a splint to keep your foot and ankle from moving. Operative treatment of posterior malleolar fractures. Avulsion fractures of the medial tubercle of the posterior process of the talus. Fig. A surgical technique for treatment of posteromedial talus fractures involving both the ankle and subtalar articulations is described in detail and results in 10 patients treated successfully with this technique are reviewed. Most posterior malleolus fractures are associated with another injury, usually a fracture of the lateral malleolus. Seven patients exhibited posterior process fractures associated with concomitant subtalar dislocation, three talar body involvement and two concomitant avulsion fracture of lateral malleolus. Tape it and forget it. AP: avulsion fracture, joint >2mm wide. Diagnosis of medial tubercle fractures of the talar posterior process using oblique views. Foot Ankle 13, 453457 (1992). 2013;80(2):165-70. Typically, surgeons will immobilize the ankle and allow the incisions to heal before initiating physical therapy. Use of a 30-degree external rotation view for posteromedial tubercle fractures of the talus. Clin. 247, Renming Road, Jiangbei District, Ningbo, Zhejiang, China, Department of Orthopaedic Surgery, Ningbo No. CAS Ebraheim, N. A., Skie, M. C. & Podeszwa, D. A. Medial subtalar dislocation associated with fracture of the posterior process of the talus. There is likely to be tenderness and possibly swelling over the sinus tarsi. Most avulsion fractures heal very well without surgical intervention. 1). The groove for the flexor hallucis longus tendon between the two tubercles is located in the middle. Twelve Asian patients with talar posterior process fracture were treated with two techniques and followed up in this study. The images or other third party material in this article are included in the article's Creative Commons licence, unless indicated otherwise in a credit line to the material. Terminology For clinical assessment, considerable mprovements were observed for the AOFAS and VAS scores at 4 and 12months postoperatively for both techniques. https://doi.org/10.1177/107110079601700408 (1996). Complications such as wound infection, nerve injury, screw loosening, malunion or nonunion of fracture were absent. 17, 226229. In humans and many other primates, the calcaneus ( / klkenis /; from the Latin calcaneus or calcaneum, meaning heel [1]) or heel bone is a bone of the tarsus of the foot which constitutes the heel. Exclusion criteria included surgeries on open posterior process fractures and additional procedures due to talar body and neck fractures. TREATMENT 22. It will be this fragment where fixation efforts will be focused. and transmitted securely. This study was conducted in accordance with the World Medical Association Declaration of Helsinki and approved by the Ethics Committee of the affiliated hospital of the Medical School of Ningbo University. anteroposterior, mortise and lateral views). The purpose of this study was to provide an initial assessment of treatment for talar posterior process fractures using ORIF through posteromedial approach and percutaneous screw fixation. By far the rarest foot and ankle fractures are those of the posterior process of the talus2. Ankle fractures (broken ankle). Trauma Surg. doi:10.1097/BOT.0000000000000763, Smeeing DPJ, Houwert RM, Kruyt MC, Hietbrink F. The isolated posterior malleolar fracture and syndesmotic instability: a case report and review of the literature. 2,8 . AJR Am J Roentgenol. An open fracture should be treated as a medical emergency. 3, 8592. Therefore, adoption of the surgical option depends on the degree of joint involvement and the degree of displacement of the posterior process fragment. The talus is the key articular segment linking the leg and foot, and as such, is subject to complex loads and may occasionally fracture. Posterior Malleolus Fractures Posterior malleolus fractures can be challenging to an orthopedist since the fracture pattern is often irregular. But if you have chronic pain, if you think you have posterior ankle pain where you might have problems with your posterior process, or you think maybe you sprained your ankle and maybe somethings broken and got missed, join us for the masterclass, the web class that we do on ankle pain in runners, and I think youll learn a lot about some of the things you can check all on your own, and some other questions you can ask your doctor so that you can make sure that you can get that better and get back to running as quickly as possible. You are using a browser version with limited support for CSS. https://doi.org/10.1016/j.jvir.2012.09.006 (2012). The majority of the talus is articular cartilage so screws may be passed from posterior to anterior through the small non-articular portion of the bone. #432 3 reasons runners get black toenails, #434 Top 3 tips to avoid bruising your toenails during long runs . The scores using the percutaneous screw technique were improved from 63.5 to 84.1 at 4months postoperatively and to 83.9 at 12months postoperatively (Table 1). Complications include avascular necrosis , posttraumatic arthritis , and union issues (e.g., malunion, To the authors knowledge, no study in the literature described in detail the initial assessment of ORIF and percutaneous screw fixation treatments. 57, 643646. 2020 Feb 11;15(1):45. doi: 10.1186/s13018-020-1560-8. Jonathan Cluett, MD, is a board-certified orthopedic surgeon with subspecialty training in sports medicine and arthroscopic surgery. The fracture fragments were reduced and fixed temporally with Kirschner wires. K. Ramachandra Kamath, Sharan Mallya & Atmananda Hegde, Zhongzheng Wang, Yuchuan Wang, Yingze Zhang, Leon-Gordian Koepke, Annika Heuer, Lennart Viezens, Scientific Reports The FHL tendon served as a marker of fracture reduction. Therefore, this technique is the most common treatment described in previous literature12,13,14. Doc on the run. Accessibility Fracture patterns provide clues to the underlying pathomechanics and energy of the injury, both of which can help guide treatment and suggest prognosis. Repeat surgical intervention after an index treatment of a talus fracture can stem from treatment of infection, reconstruction of a malunion, revision fixation of a nonunion, or fusion/joint reconstruction of post . Chen, Y. J., Hsu, R. W., Shih, H. N. & Huang, T. J. Fracture of the entire posterior process of talus associated with subtalar dislocation: a case report. Moreover, there is little consensus on how best to stabilize the fracture once it has been reset. - pt will note persistent pain, esp w/ extreme plantar flexion & limitation of subtalar motion; ORIF was performed in four of the cases and percutaneous screw fixation was performed in eight of the cases. This site needs JavaScript to work properly. Biomechanical efficacy of four different dual screws fixations in treatment of talus neck fracture: a three-dimensional finite element analysis. So this is a foot model here, and if you can see this, this is the talus bone, this bone right here, its in between, you have the heel bone that you stand on, then you have your tibia up here, and in between the tibia and the heel bone is your talus. That ones longer, so its called the flexor hallucis longus tendon. It forms a joint with the talus bone, the subtalar joint. Excision of ununited fractures of the posterior process of the talus: a treatment for chronic posterior ankle pain. . - decreased & painful motion of ankle and subtalar joints; a case report. Google Scholar. Epub 2012 Feb 21. The neurovascular and soft tissue conditions were assessed and recorded preoperatively. New Zeal. Naranja, R. J. Jr., Monaghan, B. In general, these injuries are described as tibial plafond fractures (plafond referring the part of the tibia where joint articulation occurs). Haijiao Mao. Displacement greater than 2 mm requires operative treatment for most talar head, body, and process fractures ( Sanders 2010 ). AVN occurred more often in cases of a combined neck-body fracture, than in cases of isolated body or neck fractures. The injuries can be divided anatomically into osteochondral, lateral process, posterior process, and true body (dome) fractures. doi:https://doi.org/10.1016/j.fas.2018.11.013 (2018). Request PDF | Posterior Talar Process Fractures | A posterior talar process fracture is an uncommon injury and the literature on the subject is limited as a result. Foot Ankle Surg. If they do that and they have pain in the back of the ankle, that can signify that you actually have inflammation of that tendon, or you have inflammation and irritation of the posterior process of the talus, so thats something to think about and check. The percutaneous screw fixation and ORIF techniques were performed for posterior talar process fracture in accordance with fracture displacements. This current concepts review discusses the pathomechanics, presentation, workup, treatment, and prognosis of fractures of the talar head, neck, body, lateral process, posterior process, and talar extrusions. 2019 Aug 7;20(1):363. doi: 10.1186/s12891-019-2738-2. Serbest S, Tiftiki U, Tosun HB, Kesgin E, Karata M. Isolated posterior malleolus fracture: a rare injury mechanism. Am. All patients were treated with the same postoperative procedures, casted with below knee splints for six weeks. The study aimed to observe and provide anatomical data related to posterior process of talus in Asian adults and explore the . Open Access This article is licensed under a Creative Commons Attribution 4.0 International License, which permits use, sharing, adaptation, distribution and reproduction in any medium or format, as long as you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons licence, and indicate if changes were made. Telephone: 410.494.4994. & Suleiman, J. The blue arrow is the flexor hallucis longus tendon. Symptoms of a Talus Fracture Talus Fracture symptoms vary depending on the type of fracture. Fractures of talar posterior process are very uncommon injuries as these fractures cannot be discovered with standard X-ray 1,2.This type of fracture may result in severe complications due to . Biz C, Golin N, De Cicco M, Maschio N, Fantoni I, Frizziero A, Belluzzi E, Ruggieri P. BMC Musculoskelet Disord. Axial view of CT scans showing that the internal fixation was performed properly. Anyone you share the following link with will be able to read this content: Sorry, a shareable link is not currently available for this article. Things are slightly different now with most surgeons agreeing that the size of the fragment is not the critical factor. https://doi.org/10.1302/2058-5241.3.170040 (2018). Subtalar dislocation accounts for 12% of all dislocations which makes treatment methods of talar posterior process fracture extremely rare10. Diagnosis of medial tubercle fractures of the talar posterior process using oblique views. Cadaver specimen with tibial neurovascular bundle accompanied with the FHL tendon, which is located at the level of the posterior ankle joint. Theres one thats short that starts within the foot, and then theres a long one that starts up in your leg and ends at the toe. Statistical differences between the times of clinical and radiographic resultswere analyzed using One-Way ANOVA test followed by post hoc multiple comparison with Bonferroni test. When most people describe an ankle fracture, they generally mean it to involve lower parts of the tibia and/or fibula. To obtain No complications such as screw loosening, nonunion, or malunion were reported and no patients complained about stiffness of the ankle and subtalar joint. Further future, randomized trials will help determine whether percutaneous screw fixation associated with posterior talar process fracture truly influences the rate of subtalar arthritis formation when compared with the ORIF technique with posteromedial approach. Talus fracture treatment. Some studies reported different types of posterior process fractures, however, none of them defined an optimized approach and treatment. Foot Ankle Surg. Correlation factors for distal syndesmosis ossification following internal fixation of ankle fracture, A comparative study of operative and conservative treatment of intraarticular displaced calcaneal fractures, Arthroscopy Assisted Reduction Percutaneous Internal Fixation versus Open Reduction Internal Fixation for Low Energy Tibia Plateau Fractures, A new surgical strategy for the treatment of tibial pilon fractures with MIPO facilitated by double reverse traction repositor, Application of the multiplanar fracture redactor in the treatment of tibial shaft fractures with intramedullary nails, Dual plating or dual plating combined with compression bolts for bicondylar tibial plateau fractures: a retrospective comparative study, The limitations of fully threaded screws in isolated percutaneous transarticular screw fixation of C1/C2, Comparison of Clinical Efficacy of Lateral and Lateral and Medial Double-plating Fixation of Distal Femoral Fractures, Low occupancy rate of the pedicle screw in the vertebral body leads to upper instrumented vertebral fracture, https://doi.org/10.1097/BOT.0b013e31804ea0d9, https://doi.org/10.1177/107110079601700408, https://doi.org/10.1016/j.injury.2014.12.002, https://doi.org/10.1097/BPB.0b013e328351419c, https://doi.org/10.1007/s00402-007-0459-8, https://doi.org/10.1302/2058-5241.3.170040, https://doi.org/10.1016/j.fas.2018.11.013, https://doi.org/10.1053/j.jfas.2016.02.001, https://doi.org/10.1097/MD.0000000000013331, https://doi.org/10.1177/107110079801900414, https://doi.org/10.1053/j.jfas.2012.02.007, https://doi.org/10.3109/08941939.2012.740146, https://doi.org/10.1016/j.injury.2007.04.025, https://doi.org/10.1111/j.1445-2197.1987.tb01441.x, https://doi.org/10.1177/107110079801900915, https://doi.org/10.1186/s12891-019-2603-3, https://doi.org/10.1097/00005131-199602000-00014, https://doi.org/10.1016/j.fas.2012.01.003, https://doi.org/10.1016/j.jvir.2012.09.006, https://doi.org/10.1097/BOT.0000000000001326, http://creativecommons.org/licenses/by/4.0/, Anatomical observation, classification, fracture and finite element analysis of the posterior process of the Asian adult talus. Access and reduction of displaced or comminuted fracture fragments is a challenging procedure for surgeons due to the rarity of fractures of entire posterior process. Mao, H., Shi, Z., Liu, Z., Wang, H. & Xu, D. Minimally invasive technique for medial subtalar dislocation associated with navicular and entire posterior talar process fracture: a case report. If your fracture is stable and your joints are well-aligned, surgery may not be necessary. The .gov means its official. Total recovery time is between four to six months, although it may take longer for more severe injuries. Shi, Z., Zou, J. (A, B, C) for each encounter where the patient is receiving active treatment for the fracture. . The average follow-up period was 13months. Yaw Boachie-Adjei, MD, is a board-certified, double-fellowship Orthopedic Surgeon. Type of fracture may be difficult to reset and stabilize. 10.1136/bcr-2012-007763; Guler F, Ozyurek S, Turan A, Kose O: A large bone fragment posterior to talus following medial subtalar dislocation. Mills, H. J. Talar head fractures can be treated conservatively if nondisplaced, warranting careful radiographic and CT evaluation to assess rotation, displacement, and extension into the neck. Melenevsky Y, Mackey RA, Abrahams RB, Thomson NB 3rd. He served as assistant team physician to Chivas USA (Major League Soccer) and the United States men's and women's national soccer teams. The splint should extend from the toe to the upper calf. Though uncommon, in some cases, people may need to undergo surgery to have the surgical hardware removed later on down the road. Incidentally, it is the middle facets of the subtalar joint which are most commonly involved in talocalcaneal coalition accounting for 45% of tarsal coalitions. The most common site of talus fractures is at the talar neck followed by the lateral process. The patient can be immobilized in a short-leg walking cast with the foot in 15 degrees of equinus for 4-6 weeks [ 12 ]. 26, 204209. 2012 Apr;29(2):187-203, vii. Trauma 10, 142144. Internal fixation was designed to perform as internal fixation compression with a cannulated screw. The posterolateral approach involves a longitudinal incision between the lateral border of the fibula and the Achilles tendon26. https://doi.org/10.1111/j.1445-2197.1987.tb01441.x (1987). Crutches are advised initially. Majeed, H. & McBride, D. J. Talar process fractures: an overview and update of the literature. The minimally invasive percutaneous screw fixation technique was described by few reports8,15,27,28. . And so what does that mean? - lateral tubercle has an articular surface, & frx thru this tubercle is often associatted w/ arthrosis; - Frx of Medial Tubercle: The minimally invasive surgical technique of fracture fixation was modified according to the method described in Mao et al.8,15. ORIF for extensive posterior talar fractures has been reported to provide good functional outcome, quality of life and patient satisfaction11. However, it is apparent that . J. Orthop. sharing sensitive information, make sure youre on a federal 2022 Dotdash Media, Inc. All rights reserved. Learn how we can help. S92.101 Unspecified fracture of right talus. Podiatry Today. In the meantime, to ensure continued support, we are displaying the site without styles The Cedell's fracture was first described as a medial tubercle fracture due to talotibial ligament avulsion. Our study suggests that the two fixation techniques that were investigated are ideal methods for posterior talar process fracture with good clinical outcomes. A previous study claimed that two oblique views at 45 and 70 of external rotation may be helpful, if the plain radiographs are unclear20. Aust. Talus fractures have a wide variety of presentation from low-energy avulsion fractures of the lateral or posterior processes, to high-energy comminuted talar body fractures. Verywell Health's content is for informational and educational purposes only. Horterer, H. et al. 2, 10, 11 Non weight-bearing and short leg casts are recommended for 4 to 6 weeks followed by 2 weeks of weight bearing to tolerance. An avulsion fracture occurs when a small chunk of bone attached to a tendon or ligament gets pulled away from the main part of the bone. Hawkins, L. G. Fracture of the lateral process of the talus. Valderrabano, V., Perren, T., Ryf, C., Rillmann, P. & Hintermann, B. Snowboarder's talus fracture: treatment outcome of 20 cases after 3.5 years. Use of a 30-Degree External Rotation View for Posteromedial Tubercle Fractures of the Talus. Sign up for the Nature Briefing newsletter what matters in science, free to your inbox daily. Closed reduction of the subtalar dislocation was performed initially in this study. - minimally displaced fractures are treated w/ short leg cast for 4 to 6 weeks; The majority of posterior process fractures cases are associated with concomitant subtalar dislocation. & Zhang, L. Medial subtalar dislocation associated with fracture of the posterior process of the talus. It should be noted, that the AOFAS score is currently not validated for most authors in the literature. Please enable it to take advantage of the complete set of features! The internal fixation of the fractures was confirmed with X-ray and CT scans after one day of operation (Fig. Treatment is based on the alignment of the bones and the stability of the ankle joint. This comes from a discussion I recently had with a runner during a telemedicine visit, and she called me for a second opinion. Six patients sustained open fractures and two had associated talar neck fractures. & Horne, G. Fractures of the lateral process of the talus. J. Intraoperative photo of percutaneous screw implanted with the minimally invasive technique. Radiographics. Normally a towel or rope works well. The first phase of rehab will be focused on restoring mobility to the ankle joint, followed by weight-bearing exercises once the fracture has started to heal. https://doi.org/10.1016/j.fas.2012.01.003 (2012). https://doi.org/10.1177/107110079801900915 (1998). This is due to attachments of ligaments between the two bones. Update on talar fracture patterns: a large level I trauma center study. Key words: talus, fracture, talar neck, talar head, talar body, lateral process, posterior process, talar extrusion, orthopaedic surgery, review. Minimal displacement of fracture fragment with percutaneous screw fixation was recommended. Relat. Your doctor may give you pain relief medications to help reduce swelling. Veazey, B. L., Heckman, J. D., Galindo, M. J. Bookshelf Foot and Ankle 10, 235238 (1990). Google Scholar. Surg. Treatment options for the talar neck fracture and medial and lateral tubercle fracture of posterior talar process were described in most reports. Treatment of an avulsion fracture typically includes resting and icing the affected area, followed by controlled exercises that help restore range of motion, improve muscle strength and promote bone healing. Open Orthop J. Fractures of the talar dome may be further classified into coronal . However, when talus fractures do occur they are high risk injuries that often present difficulties in management, and therefore only a limited subset of fractures are amenable to treatment in the primary care setting [ 2 ]. The patient is a 27-year-old male with left talar neck fracture (Hawkins type-2) (a, b).The X-ray after closed reduction showed a good position (c, d).Percutaneous insertion of guide wires and screws from posterior to anterior were used along the guide wires for fixation (e, f).Hawkins sign was found at eight weeks post-operatively (g, h).The follow-up CT showed that the fracture was union . & McGanity, P. L. Excision of ununited fractures of the posterior process of the talus: a treatment for chronic posterior ankle pain. The experiment was conducted in accordance with the Declaration of Helsinki (World Medical Association). But it's a nice way of mobilizing the talus without having to think about it. Department of Orthopaedic Surgery, The Affiliated Hospital of Medical School, Ningbo University, No. This could be a subtle difference to a type 3 talus fracture and was not originally part of the classification system. malleolus; with fixation of posterior lip 27826 Open treatment of fracture of weight bearing articular surface/portion of distal tibia (eg, pilon or tibial plafond), with internal fixation, when performed; of fibula only . https://doi.org/10.1097/BPB.0b013e328351419c (2012). Surgical treatment of lateral and posterior process fractures of the talus: Mid-term results of 15 cases after 7 years. 2017;11:732-742. doi:10.2174/1874325001711010732, Gibson PD, Bercik MJ, Ippolito JA, et al. Acta Orthop. The current study was a retrospective, observational investigation, in which patients diagnosed with fractures of talar posterior processes involving an isolated fracture of either medial or lateral tubercle or entire posterior process fractures participated from January 2014 to December 2018. Conservative treatment is recommended for stable and nondisplaced fractures and typically involves a non-weight-bearing, short leg cast for 6-8 weeks. Res. Careers. Rehabilitation is similar to that used for other types of ankle fracture. Citation, DOI & article data. Fractures of talar posterior process have three types, namely an isolated fracture of either medial or lateral tubercle and a simultaneous fracture of medial and lateral tubercles (i.e. 47, 11701175 (1965). All told, isolated posterior malleolus fractures account for only around 1% of ankle fractures. 128, 593598. TREATMENT Goals of treatment: 1. Scand. https://doi.org/10.1097/MD.0000000000013331 (2018). The posterolateral or posteromedial approach was performed with ORIF for posterior process fractures, according to the location of the displaced fragments. The technique involved placing one or two cannulated screws to stabilize the fracture with percutaneous screw fixation. (A) Lateral tubercle of posterior talar process; (B) medial tubercle of posterior talar process; (C) groove of the flexor hallucis longus tendon; (D) posterior talofibular ligament; (E) calcaneofibular ligament. Elevating the foot above the level of the heart helps to minimize swelling and pain. Copyright 2015. doi:https://doi.org/10.1177/0363546504271001 (2005). Talar stress fracture symptoms. The approach of the ORIF surgical technique was modified according to the method described in Shi et al19. A. Diagnosis is made radiographically with foot radiographs but CT scan is often needed for full characterization of the fracture. The posterior process has both a posteromedial tubercle and posterolateral tubercle. ORIF is a complicated technique due to the complex anatomical structure close to the ankle joint, subtalar joint, neurovascular bundle and flexor hallucis longus tendon. Implementation of the minimally invasive technique allows easy access for fracture fixation, minimization of intraoperative risk of traction lesion of neurovascular structures, and shortening of operation time and rehabilitation period. And because the tissue is relatively thin there, it is not uncommon to have an open fracture (one in which the skin is broken). Nonsurgical treatment includes restricted weight-bearing, patellar tendon-bearing braces, and extracorporeal shockwave therapy. Choice of optimal treatment methods depends on fragment size, degree of displacement, subtalar joint involvement and articular surface intervention. A malalignment of as little as two millimeters in the ankle joint can lead to arthritis. 56, 187190. Wolf, R. S. & Heckman, J. D. Case report: fracture of the posterior medial tubercle of the talus secondary to direct trauma. J. Treating complicated ankle fractures. The clinical data was offered by K.W.. Tucker, D. J., Feder, J. M. & Boylan, J. P. Fractures of the lateral process of the talus: two case reports and a comprehensive literature review. Foot Ankle Int. talar body fractures were studied retrospectively to assess outcome after operative treatment. American Academy of Orthopaedic Surgeons. Article Data Trace Publishing Company Treatment usually includes a period of immobilization followed by gradual return to activity. Answer From Edward R. Laskowski, M.D. A minimally invasive approach, which minimized the intraoperative risk of lesion of neurovascular structures, was described and preoperative individual planning with computer-assisted three-dimensional techniques for positioned percutaneous screws was recommended. Article doi:https://doi.org/10.1007/s00402-007-0459-8 (2008). The fracture itself may take place on the bulbous ends of the bones known as the malleoli, which include: Of these, the posterior malleolus is the structure least likely to be fractured on its own. The posteromedial approach is a popular incision, used by the majority of surgeons. Previously, we described a case and defined a safe zone for percutaneous screw fixation8,15. The role of computed tomography in surgical planning for trimalleolar fracture. 6, 21, 23, 24. Search. It is considered a serious injury which is often accompanied by ligament damage and dislocation of the ankle. 4). Therefore, most authors in the literature consider that if the displacement of the fracture fragment is larger than 2mm and subtalar joint surface is involved, then an urgent open reduction and internal fixation is recommended9,16. - active flexion of great toe may also produce pain as FHL moves over fracture site (between medial & lateral tubercles;) Some studies in the literature have reported that up to 40% of these fractures may be missed on initial presentation using X-ray 21,22,23. 27816 - Closed treatment of trimalleolar ankle fracture. Tibia sebanyak 59.5% dibanding pada remaja mempunyai ujung atas yang melebar dan (16-19 tahun) sebanyak 31.8%, dan anak- ujung bawah yang lebih kecil, serta sebuah anak (1-16 tahun) 8.7%.6 Tempat paling corpus.10 sering terjadinya . Get the most important science stories of the day, free in your inbox. How your fracture is treated depends on which type it is and what caused it. 6). Read our, Bimalleolar and Trimalleolar Ankle Fractures, Medial Malleolus Fracture and Broken Ankle Treatment, Physical Therapy Exercises After a Tibial Plateau Fracture, Common Fractures of the Leg, Ankle, and Foot, The Causes and Treatment of Foot and Ankle Stress Fractures, Posterior Tibial Tendonitis Signs and Treatment, Isolated posterior malleolus fracture: a rare injury mechanism, Operative treatment of posterior malleolar fractures, The isolated posterior malleolar fracture and syndesmotic instability: a case report and review of the literature, Addressing posterior malleolar ankle fractures, The posterior malleolus situated on the lower back side of the tibia. Thank you, {{form.email}}, for signing up. & Schepers, T. Functional outcome and quality of life after nonoperative treatment of posterior process fractures of the talus. Disord. J. Orthop. The posterior process of the talus is composed of medial and lateral tubercles, separated by the groove for the flexor hallucis longus tendon. 28445 Open treatment of talus fracture, includes internal fixation, when performed 28465 Open treatment of tarsal bone . Fractures of both tubercles will usually be treated conservatively if there is minimal displacement. and L.Y. J. Informed consent was obtained from the patients who participated in this study. Among the twelve patients that participated in this study, eight were male and four female, of Asian origin, with an average age of 38years, ranging from 25 to 58years. Talar Fractures and Dislocations: A Radiologist's Guide to Timely Diagnosis and Classification. Article The fractures were classified as coronal (11), sagittal (6) and crush fractures (2). Talus fractures. The talus is a small bone of the ankle responsible for transferring weight bearing forces from the shin to the foot (figure 1). Clinical outcome based on https://doi.org/10.1177/1071100719868712 (2019). So theyre relatively rare injuries, Ill tell you that, but because theyre relatively rare, theyre also sometimes missed. Clin Podiatr Med Surg. Eisenstein N, Hillier D, Ahmad S: Medial subtalar dislocation with navicular and posterior talar process fracture: the first report in the literature. Bone Joint Surg. entire posterior process fractures). Pain score and function were evaluated using the American Orthopedic Foot and Ankle Society (AOFAS) AnkleHindfoot score. And this study stressed early surgical intervention in displaced fracture of the talar posterior process fracture. It's also not very comfortable. ISSN 2045-2322 (online). But in either case, if your pain is on the back of your ankle and it hurts when you do stuff with your big toe, for example, if youre doing calf raises, if you stand up on the balls of your feet and your heels are way up off the ground, then youre having to pull hard with your big toe to maintain your balance in that position. J. Orthop. talar neck fracture with posteromedial extrusion of the talar body should be treated operatively, even in patients with significant neuropathy, to relieve soft-tissue and/or neurovascular compromise. In some other animals, it is the . No infection or nerve injury was observed in both groups. The tibia is commonly referred to as the shin bone, while the fibula is the thinner leg bone adjacent to it. The clinical and radiological results were assessed after 4 and 12months of operation with Visual Analog Scale (VAS) pain and American Orthopedic Foot and Ankle Society (AOFAS) scores. BMC Musculoskelet. Physical therapy consisting of passive and active assisted and resisted ankle range-of-motion exercises was performed during these days8. Even a minimal displacement of the fracture fragment may result in substantial joint misalignment and posttraumatic arthritis, posterior impingement and entrapment of the flexor hallucis longus tendon due to tibiotalar and talocalcaneal joints. Chirop. (A) Medial ankle; (B) achilles tendon; (C) entry point of percutaneous screw. Elderly patients with limited ambulatory capacity, similarly, may be best treated nonoperatively if the joint is not significantly displaced in posterior impingement is believed to be the result of bone impaction and thus represents bone contusions or occult fractures. J. Data Trace is the publisher of Assoc. Initial assessment of treatment of talar posterior process fractures with open reduction and percutaneous fixation. Arch. The raw data were acquired in DICOM format and reconstructed into 3D models using the software MIMICS 15.01 (Materialise's interactive medical image control system, Leuven, Belgium, https://www.materialise.com/mis)15. Immediate first aid treatment for a talus fracture, as with any painful ankle injury, is to apply a well-padded splint around the back of the foot and leg from the toe to the upper calf to immobilize the limb and protect it. Verywell Health articles are reviewed by board-certified physicians and healthcare professionals. 18, 219228. The Cedells fracture was first described as a medial tubercle fracture due to talotibial ligament avulsion. Well, theres a groove right there, and the thing that sits in this groove at the back of the posterior process, it runs right through that groove, well thats the flexor hallucis longus tendon goes through there. Immediate first aid treatment for a talus fracture, as with any painful ankle injury, is to apply a well-padded splint around the back of the foot and leg to immobilize and protect the limb. Fractures of talar posterior process are very uncommon injuries as these fractures cannot be discovered with standard X-ray1,2. The main manuscript text was written by H.M. 28430 - Closed treatment of talus fracture. Clipboard, Search History, and several other advanced features are temporarily unavailable. The wound was closed and stabilized using a dry and sterile bandage, then a below-knee splint was applied, and patients were permitted non-weight bearing mobility with the use of crutches. Skin incision was performed from the medial malleolus proximally to the calcaneal tuberosity distally and then the incision was continued along the middle line between the anterior edge of the Achilles tendon and the posterior border of the medial malleolus. 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