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CASE REPORT
Year : 2014  |  Volume : 41  |  Issue : 1  |  Page : 50-53

Management of 1½ month old neglected talus neck fracture: A case report and review of literature


Department of Orthopaedics, Jawaharlal Nehru Medical College, KLE University, Belgaum, Karnataka, India

Date of Web Publication7-Feb-2014

Correspondence Address:
Nikhil A Khadabadi
Yaamini, Plot No. 16, 5 Cross, Azam Nagar, Belgaum - 590 010, Karnataka
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/0974-5009.126757

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  Abstract 

Undisplaced talus neck fractures are uncommon and difficult to diagnose. We present a case of an 18-year-old female came with the complaints of pain and swelling in the foot following a fall from a bicycle 1½ months back. For the above complaints, she had consulted local doctors who had done X-rays of the foot and no diagnosis was made. She was treated conservatively with medications and compression bandage for swelling and the patient was allowed to walk. On presenting to us, X-ray of the foot was done and minimally displaced talus neck fracture was suspected. Magnetic resonance imaging of the foot was done and the diagnosis was confirmed. Patient was operated with percutaneous screw fixation following which below knee cast was given for 6 weeks followed by partial weight bearing. Patient returned to complete weight bearing and previous activity level without pain at the end of 3 months.

Keywords: Fracture, neck, neglected, percutaneous screw, talus


How to cite this article:
Kale DR, Khadabadi NA, Putti B B, Jatti RS. Management of 1½ month old neglected talus neck fracture: A case report and review of literature . J Sci Soc 2014;41:50-3

How to cite this URL:
Kale DR, Khadabadi NA, Putti B B, Jatti RS. Management of 1½ month old neglected talus neck fracture: A case report and review of literature . J Sci Soc [serial online] 2014 [cited 2019 Oct 13];41:50-3. Available from: http://www.jscisociety.com/text.asp?2014/41/1/50/126757


  Introduction Top


Fractures of the talus are uncommon and rank second in frequency (after calcaneal fractures) of all tarsal bone injuries. The incidence of fractures of the talus ranges from 0.1% to 0.85% of all fractures. [1] The integrity of the talus is critical to normal function of the ankle, subtalar, and transverse tarsal joints. It is a crucial intercalary articular segment connecting the leg to foot and it is unique because it is the only tarsal bone, which lacks muscular and tendinous attachments. Undisplaced and fractures of the talus typically go missed as seen in previous studies, which show that 39% of the ankle and midfoot fractures could be missed during the initial evaluation due to an inadequate clinical and radiological evaluation. [2],[3] Nearly 50% of these fractures are in talus bone. A thorough evaluation should be performed with computed tomography (CT) or magnetic resonance imaging (MRI) if there is any suspicion of fracture as each fracture is associated with high complication rates, which include avascular necrosis (AVN), collapse, malunion, secondary osteoarthritis. [4],[5],[6],[7] In our case, we aim to highlight the diagnostic evaluation with higher imaging, which should be carried out in suspected cases of talus neck fracture and management of the same.


  Case Report Top


This was a case report of an 18-year- old female patient presented with the complaints of pain in the foot on walking. The pain was present for 1½ months. She gave a history of fall from a bicycle 1½ month back following which she complained of pain the foot. The pain was dull aching in nature and it used to increase on standing and walking. She consulted a local doctor for the pain who did X-ray of the ankle joint and foot (antero posterior and lateral). No diagnosis of fracture was made on the X-ray and the doctor treated the injury as ankle sprain and advised compression bandage and anti-inflammatory medication. Pain did not subside on taking the medication for which she consulted another doctor and again no diagnosis was made and anti-inflammatory medications was asked to be continued. She presented to us 1½ months after the fall. On X-ray of the foot minimally displaced fracture of the neck of the talus was suspected [Figure 1] and [Figure 2]. MRI scan of the foot was done which confirmed our diagnosis [Figure 3] and [Figure 4]. Patient was operated because of the displaced nature of the fracture and was explained about the risk of AVN.
Figure 1: Pre-operative X-ray of the lateral view of the left foot showing minimally displaced fracture of the talus neck

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Figure 2: Comparative X-ray of the lateral view of the right foot showing normal anatomy

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Figure 3: Magnetic resonance imaging of the left foot showing break in continuity of talus neck in T1 weighted image

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Figure 4: Magnetic resonance imaging of the left foot showing break in continuity of talus neck in T2 weighted image

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Patient was placed in floppy lateral position on the operative table. Two stab incisions were made on the posterior aspect of the ankle joint on either side of the Tendo Achilles tendon and tissues were dissected up to the bone. Guide wires were passed form posterior to anterior direction in the talus and bone was drilled using 3.2 mm drill bit following which 4 mm fully threaded cannulated cancellous screws were passed from posterior to anterior over the guide wire. Screw placement was confirmed under C arm and Post operative X ray which was found to be satisfactory [Figure 5]. Below knee slab was given for 10 days followed by below knee cast for 6 weeks. Patient was started with partial weight bearing at the end of 2 months and by 3 rd month full weight bearing was started. Patient was examined at 3 months, 6 months, 9 months, 1 year and 2 years and X rays were done which showed fracture union [Figure 6]. On radiological examination, there was no evidence of AVN of the talus at the end of 1 year [Figure 7]. At 2 years post-operative period, patient is engaging in all routine activities and sports activities with no discomfort [Figure 8] and [Figure 9].
Figure 5: Immediate post-operative X-ray of the left foot (anterior-posterior and lateral view)

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Figure 6: At 3 months post-operative X-ray of the left foot (lateral view)

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Figure 7: At 1 year post-operative X-ray of the left foot (lateral view)

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Figure 8: Complete dorsiflexion of the left foot and ankle joint at the end of 2 years

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Figure 9: Complete plantar flexion of the left foot and ankle joint at the end of 2 years

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  Discussion Top


Talus fractures are also known as "aviator's astralagus," which has been titled by Anderson who was a consulting surgeon to the royal flying corps in the World War 1 who noted the association between talus fracture and aviation. He postulated that these injuries occurred because pilot's feet were on rudder bar at the time of the plane crash, which concentrated the force on the Astralagus. [8] Now-a-days with increased advent of safety with aviation travel talus fractures are more common with road traffic accidents. They are caused due to sudden dorsiflexion of the ankle resulting in fracture of the talar neck. Another reason for talar neck fracture is excessive force implied to talar neck by medial malleolus with abrupt inversion of the ankle. [9],[10]

Nearly 60% of the surface of the talus is covered with articular cartilage and it articulates with the tibia and fibula superiorly, navicular in the front and calcaneum inferiorly. Neck of the talus lies distal to the body and is devoid of articular cartilage and is angled 250 medial and inferior to the axis of the talar body. [11] Due to the lack of musculotendinous attachments on the talus, it derives its blood supply from the vascular sling around its neck and its perforating branches. Due to this precarious nature of blood supply and the retrograde flow of blood in the talus risk of AVN of the talus is high in displaced talar neck fractures. [12]

Wei et al. in their comprehensive study of missed fractures reported that foot was the most frequent missed fracture site (7.6%), followed by knee as 6.3%, elbow 6%, hand 5.4%, wrist 4.1%, hip 3.9%, ankle 2.8% and shoulder 1.9%. [13] To prevent the misdiagnosis Ottawa rules have been placed and should be applied to patients presenting in the out-patient department and emergency services with ankle injuries as suggested by some authors. [14] Initial clinical and radiological evaluation of these fractures is very important. If there is no fracture is seen on standard radiographs, but there is clinical evidence with pain on weight bearing and point tenderness over the talus a missed fracture should be considered and the patient should be re-evaluated with CT or MRI. [10] In our case plain radiography was inconclusive, but MRI scan confirmed the presence of talus neck fracture.

Talus neck fractures have been classified by Hawkins in to four types. [15] This classification has prognostic significance as risk of AVN can also be evaluated it. Treatment for undisplaced fracture (Type 1) has been a subject controversy where some authors advocate conservative management with below knee cast application for 8-12 weeks and others advise percutaneous screw fixation. [16] In our case, percutaneous screw fixation was carried out and it achieved a good result. For displaced fractures (Types 2-4) open reduction and internal fixation is advised. [9],[10]

 
  References Top

1.Santavirta S, Seitsalo S, Kiviluoto O, Myllynen P. Fractures of the talus. J Trauma 1984;24:986-9.  Back to cited text no. 1
    
2.Benger JR, Lyburn ID. What is the effect of reporting all emergency department radiographs? Emerg Med J 2003;20:40-3.  Back to cited text no. 2
    
3.Judd DB, Kim DH. Foot fractures frequently misdiagnosed as ankle sprains. Am Fam Physician 2002;66:785-94.  Back to cited text no. 3
    
4.Kettunen J, Waris P, Hermunen H, Hämäläinen R. Fracture of the lateral talus process. A case report. Acta Orthop Scand 1992;63:356-7.  Back to cited text no. 4
    
5.Vallier HA, Nork SE, Benirschke SK, Sangeorzan BJ. Surgical treatment of talar body fractures. J Bone Joint Surg Am 2003;85-A:1716-24.  Back to cited text no. 5
    
6.Ebraheim NA, Patil V, Owens C, Kandimalla Y. Clinical outcome of fractures of the talar body. Int Orthop 2008;32:773-7.  Back to cited text no. 6
    
7.Lindvall E, Haidukewych G, DiPasquale T, Herscovici D Jr, Sanders R. Open reduction and stable fixation of isolated, displaced talar neck and body fractures. J Bone Joint Surg Am 2004;86-A:2229-34.  Back to cited text no. 7
    
8.Anderson H. The Medical and Surgical Aspects of Aviation. London: Henry Frowde, Oxford University Press; 1919.  Back to cited text no. 8
    
9.Banerjee R, Nickisch F, Easley ME, DiGiovanni CW. Foot injuries. In: Brown BD, Jupiter JB, Levine AM, Trafton PG, Krettek C, editors. Skeletal Trauma. 4 th ed. Vol. 2. Philadelphia: Elsevier; 2009. p. 2585-618.  Back to cited text no. 9
    
10.Sanders DW. Fractures of the talus. In: Bucholz RW, Heckman JD, Court-Brown C, editors. Fractures in Adults. 6 th ed. Vol. 2. Philadelphia: Lippincott; 2006. p. 2249-91.  Back to cited text no. 10
    
11.Lamothe JM, Buckley RE. Talus fractures: A current concepts review of diagnoses, treatments, and outcomes. Acta Chir Orthop Traumatol Cech 2012;79:97-106.  Back to cited text no. 11
    
12.Gelberman RH, Mortensen WW. The arterial anatomy of the talus. Foot Ankle 1983;4:64-72.  Back to cited text no. 12
    
13.Wei CJ, Tsai WC, Tiu CM, Wu HT, Chiou HJ, Chang CY. Systematic analysis of missed extremity fractures in emergency radiology. Acta Radiol 2006;47:710-7.  Back to cited text no. 13
    
14.Glas AS, Pijnenburg BA, Lijmer JG, Bogaard K, de RM, Keeman JN, et al. Comparison of diagnostic decision rules and structured data collection in assessment of acute ankle injury. CMAJ 2002;166:727-33.  Back to cited text no. 14
    
15.Hawkins LG. Fractures of the neck of the talus. J Bone Joint Surg Am 1970;52:991-1002.  Back to cited text no. 15
    
16.Fernandez ML, Wade AM, Dabbah M, Juliano PJ. Talar neck fractures treated with closed reduction and percutaneous screw fixation: A case series. Am J Orthop (Belle Mead NJ) 2011;40:72-7.  Back to cited text no. 16
    


    Figures

  [Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5], [Figure 6], [Figure 7], [Figure 8], [Figure 9]



 

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