Article, Orthopedics

A case of closed total dislocation of talus and literature review

Case Report

A case of closed total dislocation of talus and literature review

Abstract

Total dislocation of talus is a rare and serious injury. The course in most cases is dominated by osteonecrosis, which explains the poor prognosis of this condition. Authors report a case of closed total dislocation of talus in its anterolateral variety. Reduction of dislocation had been performed in emergency by external manipulation. At the last follow-up, the ankle was painless, stable with a satisfactory mobility, and without radiologic signs of necrosis.

Total dislocation of talus is a rare traumatic lesion representing 2% to 10% of traumatic injuries of talus [1-4]. Less than 84 cases of pure total dislocation of talus have been reported in literature [5,6]. However, almost all were open and/or needed open reduction. Prognosis of this type of injuries is dominated by the risk of osteonecrosis [2]. We report a case of a closed anterolateral total dislocation of talus, treated conservatively with satisfactory functional results.

A 34-year-old man sustained a twisting injury to his left foot while falling from his motorbike. This injury results in pain and total loss of mobility of his left ankle. The overlying skin was tense, but intact. There were no other injuries. Radiographs showed a total dislocation of the talus with a concomitant lateral malleolar fracture (Figs. 1 and 2). Manipulation of the ankle was performed under general anesthesia with image guidance. After plantar flexion and traction in the axis, repositioning of talar bone was obtained. The Lateral malleolus fracture was managed by open reduction and fixation with a dynamic compres- sion plate (DCP). Reduction was stable and it has been maintained by a plaster for 2 months, followed by kinesitherapy. At the last visit, the ankle was painless, stable with a satisfactory mobility, and without radiologic signs of avascular necrosis of talus.

Total dislocation of talus is a rare injury. Functional prognosis of the ankle is threatened by osteonecrosis risk. Level of dislocation is variable; it is often of medial

pattern, but it would be anteromedial and rarely poster- omedial [7].

Physiopathologic mechanisms are still a subject of controversy. For Pennal [8], anterolateral dislocation has 2 components: forced plantar flexion and inversion. Plantar flexion leads to a tearing of collateral ligament, and the inversion causes tearing of talocalcaneus ligaments. The most accurate study of mechanisms was that of Asselineau et al [2], who described total dislocation as the maximal degree of an ankle trauma by supination, otherwise as the ultimate stage of medial undertalian dislocation. There are no standard treatment guidelines. Actually, most authors underline the importance of a prompt conservative treatment [2]. They treat by arthrodesis secondary septic and arthrosic complications. Reduction of talus dislocation has to be performed promptly to prevent skin and vascular complications [9,10]. Tibiocalcaneus joint arthrodesis has been adopted by Detenbeck and Kelley [3]; however, occurrence of ankylosis was frequent. Butel and Witvoet

[9] had bad functional results with talectomy and recommend triple arthrodesis by using talus as a graft. Some authors recommend closed reduction helped by transcalcaneus traction [10]. In the case of failure of this reduction, surgical reduction is mandatory [11-13]. The surgical treatment will allow even the reduction and also to repair capsuloligamentar structures [10,14]. Immobilization is obtained by a plaster for 4 to 8 weeks [10] or by pinning [14]. Managing total talar dislocation by conservative treatment may be marked by some complications, the most serious being osteonecrosis. For some authors, this osteonecrosis cannot be avoided [2,15]. It would be caused by lesion of capsuloligamentar and vascular structures of this area [2]. In some cases, this complication did not occur; many hypotheses were proposed. Shahraree et al

[16] think that the persistence of some ligamentar attachments, especially the deltoid ligament, may explain the nonoccurrence of necrosis. The artery of tarsal sinus is a branch of posterior tibial artery which is the main vascular structure that supplies the nonoccurrence of osteonecrosis in some cases of anterlateral dislocations. Gaskin and Pimple [5] reported 2 case of closed anterolateral dislocation treated by simple reduction. At the last

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475.e2 Case Report

Fig. 1 Closed total dislocation of left talus.

follow-up, we did not notice any radiologic sign of osteonecrosis in the case of our patient.

The conservative treatment by reduction using external manipulation of total talar dislocation, regard-

less of its pattern, is a major prognosis factor, to avoid damages of vascular structures by a surgical treatment leading to talus osteonecrosis, which is the main complication of this rare injury.

Fig. 2 Radiographs showing conservative management of total talar dislocation.

Case Report 475.e3

Abdelhalim El Ibrahimi Mohammed Shimi Mohammed Elidrissi Abdelkrim Daoudi Abdelmajid Elmrini

Department of Orthopaedic Surgery B4 UH HASSAN II of Fes, Morocco

E-mail address: [email protected] doi:10.1016/j.ajem.2010.04.021

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