. The patient can be immobilized in a short-leg walking cast with the foot in 15 degrees of equinus for 4-6 weeks [ 12 ]. Talus mobilization for ankle mobility. She got back to running, but shes had intermittent pain in the back of her ankle, not at the same place where she got the sprain, but shes had this pain thats been going on for a long time, and then she got an x-ray and someone told her she might have a posterior process fracture of the talus, but they didnt really explain exactly what that was, and so she was told to take some time off of running for a little while and see if it improves. Elevating the foot above the level of the heart helps to minimize swelling and pain. Percutaneous screw fixation treatment with computer-assisted three-dimensional evaluation shortened the operation time and reduced incidences of surgical complications. Fracture of the posterior process involves both the ankle and the subtalar joints; thus, fracture malunion can lead to arthritis in both joints 2, 3, 4. Acta Orthop. New Zeal. Jonathan Cluett, MD, is a board-certified orthopedic surgeon with subspecialty training in sports medicine and arthroscopic surgery. 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. Use of a 30-Degree External Rotation View for Posteromedial Tubercle Fractures of the Talus. a case report. The tibia is commonly referred to as the shin bone, while the fibula is the thinner leg bone adjacent to it. - patients will present with ankle sprain symptoms: TREATMENT Goals of treatment: 1. Nasser, S. & Manoli, A., 2nd. Carousel with three slides shown at a time. A CT scan is recommended in order to reveal the fracture type and assess the displacement of the fracture fragment12,29. Nonsurgical Treatment Many posterior malleolus fractures are small and do not require surgery. Minimal displacement of fracture fragment with percutaneous screw fixation was recommended. Department of Orthopaedic Surgery, The Affiliated Hospital of Medical School, Ningbo University, No. Whats the significance of that? A groove containing the flexor hallucis longus tendon along the posterior talus separates the medial and lateral tubercles of the posterior talus. Update on talar fracture patterns: a large level I trauma center study. If suspected, a computed tomography (CT) scan is generally preferred over an X-ray or MRI. The CT scan allows the surgeon to clearly see how many fragments there are and helps determine where the major fragment is located. All cases in this study were diagnosed based on CT scans, in which the fracture line and displacement were assessed for surgical protocol design. If your fracture is stable and your joints are well-aligned, surgery may not be necessary. Injury 38, 13131317. This study provided insight into our previous experience using percutaneous screw fixation and ORIF techniques for the treatment of posterior talar process fracture with clinical outcome assessment. Wijers, O., Engelmann, E. W. M., Posthuma, J. J., Halm, J. There is likely to be tenderness and possibly swelling over the sinus tarsi. Approach is based on the fracture pattern and the need for both open reduction and fixation versus closed reduction and fixation. HHS Vulnerability Disclosure, Help Knowledge of the exact fracture fragment and safe zone of fracture fixation can help reduce the risk of joint penetration and neurovascular bundle damage. Posterior talar process fractures may involve the medial or lateral tubercle of the posterior process of the talus. 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. The .gov means its official. - clinical findings: Talus fracture treatment algorithm . 57, 643646. Verywell Health articles are reviewed by board-certified physicians and healthcare professionals. The https:// ensures that you are connecting to the Mickel TJ, Andersen R, Keeling J, McKenna P. Foot Ankle Int. Trauma 21, 579582. Sci Rep 10, 20221 (2020). The talus is a small bone of the ankle responsible for transferring weight bearing forces from the shin to the foot (figure 1). Mehrpour, S. R., Aghamirsalim, M. R., Sheshvan, M. K. & Sorbi, R. Entire posterior process talus fracture: a report of two cases. The posterior talofibular ligament attaches to the lateral tubercle and flexor hallucis longus runs between these two tubercles. Fig. Use of a 30-Degree External Rotation View for Posteromedial Tubercle Fractures of the Talus. Interv. 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. & Zhang, L. Medial subtalar dislocation associated with fracture of the posterior process of the talus. That ones longer, so its called the flexor hallucis longus tendon. The clinical data was offered by K.W.. Screw placement can be done within the safe zone, avoiding lesion of neurovascular structures, with careful preoperative planning. Mao, H., Wang, H., Wang, L. & Yao, L. Definition of a safe zone for screw fixation of posterior talar process fracture by 3-dimensional technology. In total 35 cases of posterior talus fractures have been reported. Our website is not intended to be a substitute for professional medical advice, diagnosis, or treatment. Use of a 30-degree external rotation view for posteromedial tubercle fractures of the talus. 2019 Aug 7;20(1):363. doi: 10.1186/s12891-019-2738-2. 18, 219228. (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. Previously, we described a case and defined a safe zone for percutaneous screw fixation8,15. Amoretti, N. & Huwart, L. Percutaneous screw fixation of a talar fracture under computed tomography and fluoroscopy guidance. Clin. Bone Joint Surg. 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. Isolated breaks are rare, and, when they do happen, they tend to be difficult to reduce (reset) and fixate (stabilize).. Accessibility There are only a few reports about cases of entire posterior process fractures, according to previous literatures6,18. 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. The talus is shaped like a truncated cone and is wider anteriorly than posteriorly,which creates greater ankle stability in dorsiflexion. First, you'll be placed in a splint to keep your foot and ankle from moving. The posterior talar process fracture is an uncommon fracture and is frequently undiagnosed by orthopaedic surgeons. Podiatry Today. Google Scholar. Data Trace specializes in Legal and Medical Publishing, Risk Management Programs, Continuing Education and Association Management. 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. The most common site of talus fractures is at the talar neck followed by the lateral process. 23, 17111712. Nondisplaced fractures can be managed with a trial of nonoperative immobilization. doi:https://doi.org/10.1007/s00402-007-0459-8 (2008). A shift>2mm indicated significant displacement with surgical treatment. This site needs JavaScript to work properly. 41, 5256 (2002). 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. 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 . 2015;20:123. doi:10.11604/pamj.2015.20.123.6046, Duan X, Kadakia AR. doi:https://doi.org/10.1016/j.fas.2018.11.013 (2018). Mao, H., Wang, H., Zhao, J. et al. The groove for the flexor hallucis longus tendon between the two tubercles is located in the middle. https://doi.org/10.1016/j.fas.2012.01.003 (2012). American Academy of Orthopaedic Surgeons. Answer From Edward R. Laskowski, M.D. Some studies reported different types of posterior process fractures, however, none of them defined an optimized approach and treatment. #432 3 reasons runners get black toenails, #434 Top 3 tips to avoid bruising your toenails during long runs . - pt will note persistent pain, esp w/ extreme plantar flexion & limitation of subtalar motion; 247, Renming Road, Jiangbei District, Ningbo, Zhejiang, China, Department of Orthopaedic Surgery, Ningbo No. https://doi.org/10.1302/2058-5241.3.170040 (2018). & Schepers, T. Functional outcome and quality of life after nonoperative treatment of posterior process fractures of the talus. The posteromedial approach is a popular incision, used by the majority of surgeons. Content is reviewed before publication and upon substantial updates. Future studies should include more clinical cases or cadaveric studies can be used to validate these techniques. Previous reports have described that ORIF treatment leads to a different outcome9,16. 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. - frx may also occur when ankle is forced into extreme equinus; The widely preferred approach for many talar neck and body fractures is a dual anterior incision technique to achieve an anatomic reduction, with the addition of a medial malleolar osteotomy as needed to visualize the posterior talar body. The neck has approximately 15 to 20 of medial deviation and is the area most vulnerable to fractures. Talar dome injuries occur equally in men and women. The neurovascular and soft tissue conditions were assessed and recorded preoperatively. Cedell fracture: Posterior talar process fracture with injury to the posteromedial tubercle caused by forced dorsiflexion and pronation. Addressing posterior malleolar ankle fractures. The mechanism of injury may result from a posteromedial facet impaction17. The VAS scores decreased from 4.5 preoperatively to 2.0 and 1.8 at 4 and 12months post-operation, respectively, using the ORIF technique and from 5.3 to 2.2 and 1.5 at 4 and 12months post-operation, respectively, using the percutaneous screw technique (Table 2). Doc on the run. Learn how we can help. 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. To the authors knowledge, no study in the literature described in detail the initial assessment of ORIF and percutaneous screw fixation treatments. Your doctor may give you pain relief medications to help reduce swelling. The postoperative course of the patients was evaluated based on Visual Analog Scale (VAS). Assoc. - inversion of ankle may avulse tubercle leaving PTFL intact; This could be a subtle difference to a type 3 talus fracture and was not originally part of the classification system. Am. He founded Orthopaedic Specialists of North Carolina in 2001 and practices at Franklin Regional Medical Center and Duke Raleigh Hospital. 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. 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. Liu, Z., Zhao, Q. . J. Podiatry Today. (A) Lateral tubercle of posterior talar process; (B) medial tubercle of posterior talar process; (C) groove of the flexor hallucis longus tendon. A significant difference (p<0.05) was detected between AOFAS and VAS scores in the two groups preoperatively and postoperatively (Tables 3, 4). 56, 187190. 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. Kopp L, Obruba P, Riegl J, Meluzinov P, Edelmann K. Acta Chir Orthop Traumatol Cech. 45, 454461 (1974). Mobilization and protection of the neurovascular bundle is essential when accessing the fracture site. Read More. Towson, MD 21204 As the bone remains aligned after the blow, it is usually easier to treat a non-displaced fracture as compared to a displaced fracture. 3). Rehabilitation is similar to that used for other types of ankle fracture. Unable to load your collection due to an error, Unable to load your delegates due to an error. And so when I look at a patient and they tell me that theres pain on the back of the ankle here and I suspect maybe thats the flexor hallucis longus tendon where it rubs around the posterior process, what I do is I basically take them and I just push up on their big toe, I put my thumb under the big toe, and then Ill tell him to push down as hard as they can. 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 . Excellent and good results were achieved in eight (66.7%) patients, fair results were achieved in three (25%), and poor results were observed (8.3%) for the last follow-up. 27824 - Closed treatment of fracture of weight bearing articular portion of distal tibia (pilon or tibial plafond), with or without anesthesia. Citation, DOI & article data. It's also not very comfortable. 28400 - Closed treatment of calcaneal fracture. S92.10 Unspecified fracture of talus. Considerable improvements were observed in the AOFAS and VAS scores at 4 and 12months postoperatively in both fixation techniques during clinical assessment. A closed reduction and internal fixation of the posterior process of the talus using a minimally invasive approach was performed, based on the images from the preoperational simulations (Fig. - posterolateral ankle tenderness may be elicited; This project was supported by the medical and health science and technology project of Zhejiang Province (2015KYB339) and Ningbo Natural Science Foundation (2018A610266). Res. 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. Trauma 32, 601606. When most people describe an ankle fracture, they generally mean it to involve lower parts of the tibia and/or fibula. Thus, talus fractures are relatively uncommon, comprising less than 1 percent of all fractures [ 1 ]. Avulsion fractures of the medial tubercle of the posterior process of the talus. 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. The majority of posterior process fractures cases are associated with concomitant subtalar dislocation. AP: avulsion fracture, joint >2mm wide. 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. https://doi.org/10.1097/BOT.0b013e31804ea0d9 (2007). 5). The statistical significance of the difference between the groups was determined at the 0.05 significance level15. and L.Y. The study aimed to observe and provide anatomical data related to posterior process of talus in Asian adults and explore the . This technique offered a good evaluation of the fixation for talar process fractures preoperatively. Informed consent was obtained from the patients who participated in this study. The methodological improvement in this study was a good option depending upon the size and displacement of the fracture fragment. 128, 593598. If that happens and you have chronic pain, well, you need to address it. It forms a joint with the talus bone, the subtalar joint. J. Vasc. 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. & Grenier, J. M. Fracture of the lateral tubercle of the posterior talar process caused by a rock-climbing fall: a case report. 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. Cannulated screws are recommended for fracture fixation with small fracture fragments and articular cartridge. Talus fractures are significant because of their potential for long-term morbidity and complications. The posteromedial process fracture of the talus: a case report. 2017 Feb;9(1):28-33. doi: 10.1111/os.12303. In some cases, the bone will not need to be repositioned, and the fragment can be secured without surgery. Majeed, H. & McBride, D. J. Talar process fractures: an overview and update of the literature. 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. 38.3, A and B shows preoperative and postoperative radiographs of a talar neck fracture, respectively. 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. Twelve Asian patients with talar posterior process fracture were treated with two techniques and followed up in this study. Treatment usually includes a period of immobilization followed by gradual return to activity. Bookshelf This is a small canal where nerves pass . 110 West Rd., Suite 227 Talus fractures. S92.101A initial encounter for closed fracture; S92 . Ebraheim, N. A., Skie, M. C. & Podeszwa, D. A. Medial subtalar dislocation associated with fracture of the posterior process of the talus. - surgical excision of the ununited fragment thru a posterolateral ankle arthrotomy may relieve the pain. The appropriate 7th character for initial encounter should also be . sharing sensitive information, make sure youre on a federal Fractures of both tubercles will usually be treated conservatively if there is minimal displacement. doi: 10.1016/j.cpm.2012.01.005. Fractures of the talus: a comprehensive review. Intraoperative photo of ORIF. Treatment relies on appropriate diagnosis, which hinges on clinical suspicion provided by the patient's account of pathomechanics, clinical examination, and radiological workup. Sports Med. Axial view of CT scans showing that the internal fixation was performed properly. The calcaneus forms the bony part of the heel. Epub 2012 Feb 21. Valderrabano, V., Perren, T., Ryf, C., Rillmann, P. & Hintermann, B. Snowboarder's talus fracture: treatment outcome of 20 cases after 3.5 years. Radiol. Data Trace Publishing Company There were no considerable differences in AOFAS and VAS scores between the two techniques at 4 and 12months postoperatively. The experiment was conducted in accordance with the Declaration of Helsinki (World Medical Association). Cite this article. Foot Ankle Int. 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. The 3D model with medial and lateral virtual screw path of the posterior talar process. Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations. Complications such as wound infection, nerve injury, screw loosening, malunion or nonunion of fracture were absent. 19, 641646. posterior process consist of medial and lateral tubercle separated by groove for FHL Blood supply because of limited soft tissue attachments, the talus has a direct extra-osseous blood supply sources include posterior tibial artery via artery of tarsal canal (most important and main supply) supplies most of talar body via calcaneal braches All patients were treated with the same postoperative procedures, casted with below knee splints for six weeks. - treatment may involve excision of the the fragment; - Treatment: Diagnosing and Treating Posterior Malleolus Fractures. Individuals who have suffered a major foot injury due to the negligence of another person or entity should contact me at (800) 404-5400 and/or (209) 227-1931 to receive free, friendly legal guidance and advice. Conservative Treatment of Posterior Malleolus Fracture Usually, conservative treatment of posterior malleolus fracture, is recommended for less severe and uncomplicated injuries. Some fractures involve both bones; others affect only one. Fractures of the posterior process of the talus are rarely seen and frequently overlooked. Diagnosis of medial tubercle fractures of the talar posterior process using oblique views. Subtalar dislocation accounts for 12% of all dislocations which makes treatment methods of talar posterior process fracture extremely rare10. From January 2008 to December 2010, 18 patients with displaced fracture of talar poste. Diagnosis is made radiographically with foot radiographs but CT scan is often needed for full characterization of the fracture. J. Orthop. Cedell, C. A. Rupture of the posterior talotibial ligament with the avulsion of a bone fragment from the talus. Now she rolled her ankle and went to the emergency room, they gave her a brace, they gave her an ACE wrap to compress it, she was told to do some exercises, and frankly she improved a lot. Elderly patients with limited ambulatory capacity, similarly, may be best treated nonoperatively if the joint is not significantly displaced J. The tibialis posterior muscle originates from the back of the tibia and fibula (lower leg bones), it then . Federal government websites often end in .gov or .mil. Please enable it to take advantage of the complete set of features! 2022 Dotdash Media, Inc. All rights reserved. The posterior process of the talus originates from the convex-curved posterior half of the talar dome and slopes down and back to form the posterior talar "beak." Inferiorly, it is concave and articulates with the posterior subtalar facet of the calcaneus. Further-more, the fractures of the medial . 7). Though uncommon, in some cases, people may need to undergo surgery to have the surgical hardware removed later on down the road. Symptoms of a stress fracture of the talus develop gradually over time and include: Pain on the outside of the ankle. Informed consent was obtained from the patients who participated in this study. This is commonly referred to as a trimalleolar fracture in which all three bone structures are broken. 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. Biz C, Golin N, De Cicco M, Maschio N, Fantoni I, Frizziero A, Belluzzi E, Ruggieri P. BMC Musculoskelet Disord. PubMed 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. POSTERIOR . & McGanity, P. L. Excision of ununited fractures of the posterior process of the talus: a treatment for chronic posterior ankle pain. 14 As expected, there seems to be a trend of increased complication rates with a longer follow-up . The yellow arrow is a cannulated screw. (A) Flexor hallucis longus tendon; (B) posterior tibial artery; (C) plantar nerve. Thus, adequate access to the fracture fragments and using lag screws for fixation is achieved and for the neurovascular bundle to remain unharmed. 6 Hospital, Ningbo, Zhejiang, China, The Medical School of Ningbo University, Ningbo, Zhejiang, China, Department of Orthopaedic Surgery, Ningbo No. Mills, H. J. For clinical assessment, considerable mprovements were observed for the AOFAS and VAS scores at 4 and 12months postoperatively for both techniques. - Frx of Lateral Tubercle of Posterior Process (Sheppard's Frx): Safe Zone of Posterior Screw Insertion for Talar Neck Fractures on 3-Dimensional Reconstruction Model. 3, 8592. Clinical outcome of closed isolated subtalar dislocations. 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. The main manuscript text was written by H.M. Fracture patterns provide clues to the underlying pathomechanics and energy of the injury, both of which can help guide treatment and suggest prognosis. One or two screws were positioned for fixation of the medial and lateral tubercle of the posterior talar process (Fig. 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. https://doi.org/10.1038/s41598-020-77151-6, DOI: https://doi.org/10.1038/s41598-020-77151-6. These medical reviewers confirm the content is thorough and accurate, reflecting the latest evidence-based research. Surgery is the definitive treatment, indicated especially for open or displaced fractures. 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. 2012 Apr;29(2):187-203, vii. Blanchette, M. A. Scand. Disord. & Suleiman, J. 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 . Pan Afr Med J. Fractures of talar posterior processes are prone to be misdiagnosed with primary plain radiographs (i.e. Key words: talus, fracture, talar neck, talar head, talar body, lateral process, posterior process, talar extrusion, orthopaedic surgery, review. BMC Musculoskelet. Symptoms get worse with exercise, particularly running, and ease with rest. This is why postoperative care will often require the ankle to be non-weight-bearing for six weeks. Melenevsky Y, Mackey RA, Abrahams RB, Thomson NB 3rd. 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. Description. With that being said, there remains controversy as to when it is most appropriate. Your healthcare provider may recommend: Casting. https://doi.org/10.1016/j.injury.2007.04.025 (2007). The Cedell's fracture was first described as a medial tubercle fracture due to talotibial ligament avulsion. The manuscript was reviewed and revised by L.W. Shi, Z., Zou, J. Because an isolated fracture of this sort is so rare, diagnoses are sometimes missed or inconclusive. The postoperative VAS and AOFAS scores were comparable, with no significant differences between the two techniques. https://doi.org/10.1177/107110079601700408 (1996). 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. The Mann Whitney U test was used for the skewed distribution of cases. TREATMENT 35. Look-Ups. This approach is especially suitable for patients who have multiple comorbidities and a higher perioperative risk. von Winning, D. et al. 8600 Rockville Pike 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. The ankle joint is a complex junction of three bones known as the fibula, tibia, and talus. The posterolateral approach involves a longitudinal incision between the lateral border of the fibula and the Achilles tendon26. Article talar body fractures were studied retrospectively to assess outcome after operative treatment. K. Ramachandra Kamath, Sharan Mallya & Atmananda Hegde, Zhongzheng Wang, Yuchuan Wang, Yingze Zhang, Leon-Gordian Koepke, Annika Heuer, Lennart Viezens, Scientific Reports Relat. Well, she asked me, What exactly is a posterior process fracture? Well, all right, Ill show you. More often, breaks will occur when the medial and lateral malleolus are also involved. 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. The posterior talar process fractures present in the study were classified as lateral tubercle fracture, medial tubercle fracture and entire posterior process fracture. The role of computed tomography in surgical planning for trimalleolar fracture. Percutaneous screw fixation has also demonstrated success in certain patterns. 2017;31(4):e116-e120. Excision of ununited fractures of the posterior process of the talus: a treatment for chronic posterior ankle pain. Clinical outcome based on Crutches are advised initially. 226230 (1994). Additionally, ORIF with posteromedial approach was recommended for fixations of fracture fragments with large displacements that may cause incongruity in the subtalar or ankle joint. ORIF was performed in four of the cases and percutaneous screw fixation was performed in eight of the cases. Diagnosis of medial tubercle fractures of the talar posterior process using oblique views. Search. and transmitted securely. 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. Talar fractures are divided by anatomic region: head, neck, and body. By far the rarest foot and ankle fractures are those of the posterior process of the talus2. To the authors knowledge, there are few descriptions of surgical techniques for fractures of posterior talar process in the literature8,13,19. Buddy Taping/6 weeks: Non displaced fracture is treated with Buddy Taping and rigit sole shoes to limit joint movements.Buddy taping is taping the fractured toe to the next. Ebraheim, N. A., Patil, V., Frisch, N. C. & Liu, X. Terminology 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. Subsequently, the best surgical approach is still in controversy. https://doi.org/10.1111/j.1445-2197.1987.tb01441.x (1987). Clin Podiatr Med Surg. https://doi.org/10.1097/BOT.0000000000001326 (2018). The posterior process has both a posteromedial tubercle and posterolateral tubercle. Google Scholar. Treatment of posterior ankle pain by excision of a bipartite talar fragment, Fractures of the Distal Tibial Metaphysis, Orthopaedic Specialists of North Carolina. You may have to wear a cast or splint to prevent further damage. volume10, Articlenumber:20221 (2020) S92.101 Unspecified fracture of right talus. The AOFAS scores were categorized as excellent (90100 points), good (8089points), fair (7079 points), and poor (69 points)13. Intraoperative fluoroscopy photo of percutaneous screw implanted with the minimally invasive technique. - look for tenderness and perhaps a mass just posterior to medial malleolus and pain w/ motion ofgreat toe (due to motion ofFHL); By Jonathan Cluett, MD Surgical treatment of lateral and posterior process fractures of the talus: Mid-term results of 15 cases after 7 years. J. Surg. In some other animals, it is the . Among a total of 12 patients have undergone pre and post-operative 3D-CT. 2013;80(2):165-70. https://doi.org/10.1016/j.injury.2014.12.002 (2015). The Cedells fracture was first described as a medial tubercle fracture due to talotibial ligament avulsion. So sometimes a posterior process is an actual fracture, and sometimes its a natural occurrence where the bone just hasnt fully ossified, and technically you have this other thing called an Os trigonum it doesnt really matter the specifics of the terms or what that means, it just means you have a natural separation of the two pieces where it never, ever completely fused together. The skin and subcutaneous tissue were carefully dissected when close to the posterior tibial neurovascular bundle (Fig. EFORT Open Rev. Fractures of the anterior process account for approximately 15 percent of all calcaneal fractures and are commonly misdiagnosed as ankle sprains. Copyright 2015. A. https://doi.org/10.1177/1071100719868712 (2019). . In the meantime, to ensure continued support, we are displaying the site without styles de Palma, L., Santucci, A., Marinelli, M., Borgogno, E. & Catalani, A. S92.1 Fracture of talus. By submitting a comment you agree to abide by our Terms and Community Guidelines. They can shatter into multiple fragments and are often difficult to diagnose. Treating complicated ankle fractures. Posterior Malleolus Fractures Posterior malleolus fractures can be challenging to an orthopedist since the fracture pattern is often irregular. Treatment may involve wearing a short leg cast or a removable brace. To view a copy of this licence, visit http://creativecommons.org/licenses/by/4.0/. 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. 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. J. 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 . The study provided valuable information for the minimally invasive technique of posterior talar process fracture and contributed to the accuracy of this highly demanding technique. 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. J. No infection or nerve injury was observed in both groups. The posterior process is this big bump that you see sitting on the back of the talus sitting over your heel bone. Long-term radiographic and clinical-functional outcomes of isolated, displaced, closed talar neck and body fractures treated by ORIF: the timing of surgical management. There were no significant differences for AOFAS scores and VAS scores between the two groups at 4 and 12months postoperatively (p>0.05) (Tables 1,2). The posterolateral or posteromedial approach was performed with ORIF for posterior process fractures, according to the location of the displaced fragments. Scientific Reports (Sci Rep) Fractures of talar posterior process involve an isolated fracture of either medial or lateral tubercle and simultaneous fracture of the medial and lateral tubercles (entire posterior process fractures)4,6. This research was approved by the Ethics Committee of the affiliated hospital of the medical school of Ningbo University. 33, 871880. You'll need some form of immobilization like a splint or cast and might need surgery to . The minimally invasive percutaneous screw fixation technique was described by few reports8,15,27,28. Clinical and radiological outcomes of patients were assessed at 4 and 12months postoperatively. Intraoperative photo of percutaneous screw implanted with the minimally invasive technique. 4). Cadaver specimen with tibial neurovascular bundle accompanied with the FHL tendon, which is located at the level of the posterior ankle joint. Treatment is based on the alignment of the bones and the stability of the ankle joint. For clinical assessment, considerable improvements were observed for the AOFAS and VAS scores at 4 and 12months postoperatively in both techniques. Most posterior malleolus fractures are associated with another injury, usually a fracture of the lateral malleolus. government site. Would you like email updates of new search results? Because the ankle is vulnerable to twists and compression, the fracture of these bones is not uncommon and can sometimes be difficult to treat. Findings suggest that the minimally invasive fixation of posterior talar process fracture is potentially a safer and more convenient method rather than the ORIF with posteromedial approach. 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. Elevating the foot above the level of the heart helps to minimize swelling and pain. 2013 Nov;201(5):1087-92. doi: 10.2214/AJR.12.9918. Shibuya et al (PMID: 24785202) found that open fractures occur in approximately 20% of calcaneus and talus fractures. 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. 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. Fractures of talar posterior process are very uncommon injuries as these fractures cannot be discovered with standard X-ray1,2. A bone fracture is the medical term for breaking a bone. J. Pediatr. The average follow-up period was 13months. Initial assessment of treatment of talar posterior process fractures with open reduction and percutaneous fixation. Open Orthop J. 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 ]. Invest. If material is not included in the article's Creative Commons licence and your intended use is not permitted by statutory regulation or exceeds the permitted use, you will need to obtain permission directly from the copyright holder. Careers. 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. The study was performed by H.W. You are using a browser version with limited support for CSS. No patients complained of stiffness in the ankle and subtalar joint. Incidentally, it is the middle facets of the subtalar joint which are most commonly involved in talocalcaneal coalition accounting for 45% of tarsal coalitions. It should be noted, that the AOFAS score is currently not validated for most authors in the literature. If the symptoms persist; an additional period of immobilization (4 to 6 weeks) might be required. Veazey, B. L., Heckman, J. D., Galindo, M. J. Fan Z, Ma J, Chen J, Yang B, Wang Y, Bai H, Sun L, Wang Y, Lu B, Dong BC, Tian A, Ma X. J Orthop Surg Res. Less serious injuries may. Type 4 talus fractures include not only the dislocation of the body of the talus (the posterior portion) from the calcaneus but also the separation of the head of the talus from the other tarsal bones anterior to it. Created for people with ongoing healthcare needs but benefits everyone. However, it is apparent that . A minimally invasive approach for this fracture was described, which is an attractive alternative compared to major open operation. Article Posterior malleolus fractures can be challenging to an orthopedist since the fracture pattern is often irregular. J. Orthop. Diagnosis of medial tubercle fractures of the talar posterior process using oblique views. ORIF was performed when soft tissue swelling was reduced, while swelling did not affect the percutaneous screw fixation procedure. Skin sutures were removed 14days postoperatively and the operated limb was immobilized with a short non-weight bearing leg cast for another 6weeks. And this study stressed early surgical intervention in displaced fracture of the talar posterior process fracture. Am. 47, 11701175 (1965). 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. Ankle fractures (broken ankle). The remaining cases were cast before preoperative examination. Clinical outcome and concomitant injuries in operatively treated fractures of the lateral process of the talus. Fractures of the talar dome may be further classified into coronal . An open fracture should be treated as a medical emergency. Treatment. Article And sometimes patients are told that they have a posterior process fracture when they really dont. [Surgical management of talus fractures: mid-term functional and radiographic outcomes]. It will be this fragment where fixation efforts will be focused. Symptoms of a Talus Fracture Talus Fracture symptoms vary depending on the type of fracture. Complication rates were high, ranging between 6% SSI up to 64% osteoarthritis, following operative treatment of talar fractures. doi:https://doi.org/10.1177/0363546504271001 (2005). Exclusion criteria included surgeries on open posterior process fractures and additional procedures due to talar body and neck fractures. ( 20 tahun) paling tinggi dengan talus dan ujung distal fibula. Type of fracture may be difficult to reset and stabilize. Based on their description, lateral and posterior process fractures are classified into four types. also known as broken ankle , ankle fracture and malleoli fracture . 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). To obtain Foot Ankle Int. pott's fracture. Six patients sustained open fractures and two had associated talar neck fractures. (A, B, C) for each encounter where the patient is receiving active treatment for the fracture. TREATMENT 22. 27816 - Closed treatment of trimalleolar ankle fracture. 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. And so what does that mean? A survey of OTA members. 28445 Open treatment of talus fracture, includes internal fixation, when performed 28465 Open treatment of tarsal bone . 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. The AOFAS scores using the ORIF technique were improved from 64.5 to 83.5 at 4months postoperatively, and to 82.8 at 12months postoperatively. Orthopaed. https://doi.org/10.1177/107110079801900414 (1998). Therefore, adoption of the surgical option depends on the degree of joint involvement and the degree of displacement of the posterior process fragment. Treatment of posterior ankle pain by excision of a bipartite talar fragment, Clifford R. Wheeless, III, M.D. 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. https://doi.org/10.1097/MD.0000000000013331 (2018). Verywell Health's content is for informational and educational purposes only. Talar stress fracture symptoms. There are few studies about this injury in the literature and most of them are case reports6,18,25. Radiographic examination revealed a tibia plafond fracture, a distal fibula fracture and a talo-tibial divergent fracture-dislocation in the right lower extremity; while in the left lower extremity there was a fracture of the medial malleolus and an 81C3 talus body fracture according to the OTA classification. In one case series, 17 of 20 patients with fractures were . Talar fractures comprise 3%-5% of all foot and an- . AVN occurred more often in cases of a combined neck-body fracture, than in cases of isolated body or neck fractures. Internal fixation was designed to perform as internal fixation compression with a cannulated screw. 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. Can. From January 2014 to December 2018, 12 cases with displaced fracture of talar posterior process were treated in our department. He served as assistant team physician to Chivas USA (Major League Soccer) and the United States men's and women's national soccer teams. 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. Foot and Ankle 10, 235238 (1990). 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. Serbest S, Tiftiki U, Tosun HB, Kesgin E, Karata M. Isolated posterior malleolus fracture: a rare injury mechanism. 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. 58, 286290 (2014). The fracture was then reduced temporarily and stabilized with two guide pins and the reduction was confirmed with fluoroscopy. pott's fracture often occurs in combination with other injuries such as a sprained . PubMed Central https://doi.org/10.1177/107110079801900915 (1998). 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. Occult talar neck fracture associated with talar avulsion diagnosed by MRI: a case report. PubMed An official website of the United States government. Operative treatment of posterior malleolar fractures. Pain score and function were evaluated using the American Orthopedic Foot and Ankle Society (AOFAS) AnkleHindfoot score. Foot Ankle Surg. Typically, surgeons will immobilize the ankle and allow the incisions to heal before initiating physical therapy. entire posterior process fractures). 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). Treatment options for the talar neck fracture and medial and lateral tubercle fracture of posterior talar process were described in most reports. Int J Surg Case Rep. 2017;41:360-365. doi:10.1016/j.ijscr.2017.10.062. The technique involved placing one or two cannulated screws to stabilize the fracture with percutaneous screw fixation. Another way to do this is to go through dorsiflexion with a posterior glide on the talus. 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. The splint should extend from the toe to the upper calf. Ebraheim, N. A. et al. 2015 May-Jun;35(3):765-79. doi: 10.1148/rg.2015140156. 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. Differential diagnosis 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. 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. Aust. - minimally displaced fractures are treated w/ short leg cast for 4 to 6 weeks; 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. So theyre relatively rare injuries, Ill tell you that, but because theyre relatively rare, theyre also sometimes missed. Traditionally, surgeons have long recommended surgery if more than 25% of the malleoli is involved. ISSN 2045-2322 (online). (A) Medial ankle; (B) achilles tendon; (C) entry point of percutaneous screw. And because the tissue is relatively thin there, it is not uncommon to have an open fracture (one in which the skin is broken). Google Scholar. https://doi.org/10.1053/j.jfas.2012.02.007 (2012). Our study suggests that the two fixation techniques that were investigated are ideal methods for posterior talar process fracture with good clinical outcomes. - lateral tubercle has an articular surface, & frx thru this tubercle is often associatted w/ arthrosis; - Frx of Medial Tubercle: This comes from a discussion I recently had with a runner during a telemedicine visit, and she called me for a second opinion. The average follow-up period was 13months (816months). BMJ Case Rep. 2013 . Foot Ankle Surg. TIBIAL STRESS FRACTURE Reza Maulana Abstrak. You have to wear it until your bone heals completely. Letonoff, E. J., Najarian, C. B. J. Fractures that are often not out of place and in patients who are not active, can be managed well with conservative or non-surgical treatment. Further, a trial of cast immobilization of acute posterior or lateral talar process fractures of at least 6 weeks is useful, . All cases showed no screw loosening, implant breakage, nonunion, or malunion. 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. J. The blue arrow is the flexor hallucis longus tendon. Fracture patterns provide clues to the underlying pathomechanics and energy of the injury, both of which can help guide treatment and suggest prognosis. - some suggest casting in 15 deg of plantar flexion; - Complications: Haijiao Mao. 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. To evaluate the surgical outcomes of talar, posterior process displaced fractures with posteromedial approach. Treatment for a talus fracture depends on the type of fracture and the severity of your injury. Most reports of talar posterior process fractures are associated with subtalar dislocation7,8,9 and the recommended treatment is early open reduction and internal fixation (ORIF) or percutaneous screw fixation8. Horterer, H. et al. Jonathan Cluett, MD, is board-certified in orthopedic surgery. The purpose of this study was to provide an initial assessment of treatment for talar posterior process fractures using open reduction and internal fixation (ORIF) through posteromedial approach and percutaneous screw fixation. This is due to attachments of ligaments between the two bones. the best experience, we recommend you use a more up to date browser (or turn off compatibility mode in Hawkins, L. G. Fracture of the lateral process of the talus. & Yi, X. Posteromedial approach in treatment of talar posterior process fractures. Trauma Surg. 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. . - nonunions are uncommon: The cause of injury for eight of the cases was vehicle accident and for four of the cases sport injury. 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. 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 . Google Scholar. Talar head fractures can be treated conservatively if nondisplaced, warranting careful radiographic and CT evaluation to assess rotation, displacement, and extension into the neck. Foot Ankle Surg. It is considered a serious injury which is often accompanied by ligament damage and dislocation of the ankle. Conservative treatment is recommended for stable and nondisplaced fractures and typically involves a non-weight-bearing, short leg cast for 6-8 weeks. in posterior impingement is believed to be the result of bone impaction and thus represents bone contusions or occult fractures. The injuries can be divided anatomically into osteochondral, lateral process, posterior process, and true body (dome) fractures. No complications such as screw loosening, nonunion, or malunion were reported and no patients complained about stiffness of the ankle and subtalar joint. Complications include avascular necrosis , posttraumatic arthritis , and union issues (e.g., malunion, 17, 226229. 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. & Horne, G. Fractures of the lateral process of the talus. Moreover, there is little consensus on how best to stabilize the fracture once it has been reset. All told, isolated posterior malleolus fractures account for only around 1% of ankle fractures. All rights resvered. 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. 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