July 2012 Case Study of the Month. Author: Mo Mortazavi, MD

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1 July 2012 Case Study of the Month Author: Mo Mortazavi, MD CC: Left ankle injury HPI: HL is a 6 year old female who presents in consultation for a left ankle injury sustained 2 days prior to presentation. According to the parent, HL was on a rope swing when she jumped off a 4 foot height onto her ankle. She does not remember the exact mechanism, but reports that her ankle was dorsiflexed and liked everted. The patient developed immediate diffuse ankle pain, bruising, and swelling and was not able to stand. She was seen in the ED and placed into a posterior short leg splint that day. Today the patient rates her pain an 8 out of 10 and describes it as a sharp pain located over the entire ankle joint but worst on the medial aspect. It is exacerbated with any movement or palpation and improved with splinting. The patient has been taking ibuprofen and acetaminophen/hydrocodone for the pain, which helps. HL has never previously injured this body part and is otherwise healthy. PHYSICAL EXAMINATION: General: Alert and well appearing. The patient answers questions appropriately for age Neurologic: Normal muscle bulk and tone throughout, unable to weight bear, carried in. MSK: Inspection: Examination of the left ankle reveals moderate swelling over the entire ankle region, including both medial and lateral ankle. The skin examination reveals warm, pink skin without signs of infection, open lesions, redness, rash, abnormal warmth to the touch, or pustular discharge. There is ecchymosis below the medial malleolus. There is no angular or rotational deformity. Palpation: The distal tibia, tibial physis, talar neck, distal fibular shaft and physis, deltoid ligament, and distal syndesmosis are tender to palpation. There is no tenderness over the calcaneus, metatarsals, or navicular. ROM: Range of motion of the ankle is extremely limited due to pain Strength: 3/5 at right ankle in all directions due to pain but 5/5 otherwise in the right lower extremity. Neurovascular exam: The extremity is distally neurovascularly intact with brisk pulses, brisk capillary refill, and a normal motor and sensory nerve examination.

2 No special maneuvers testing was performed due to pain and known radiographic findings. DIFFERENTIAL DIAGNOSIS: Deltoid ligament tear Talus fracture OCD lesion of talus Distal tibial fracture Medial malleolus fracture Tri malleolar fracture Talleaux fracture Pilon fracture Ankle joint dislocation Syndesmosis injury Maisonneuve fracture IMAGING: There is an oblique fracture of the distal tibial metaphysis in near anatomic alignment extending to the distal tibial physis (Salter Harris II). There is subtle deformity of the distal fibular diametaphysis reflecting incomplete fracture. There is a fracture extending through the neck of the talus. A small bony fragment is seen along the lateral aspect of the talus on the AP view which reflects a loose body. Impression: Mildly displaced transverse talar neck fracture. Distal tibial and fibular fractures. Small bony fragment lateral to the talus reflecting loose body.

3 CT scan of ankle: Salter Harris II fracture of the distal tibia in near anatomic alignment with transverse buckle component and oblique anterolateral component which extends to the physis. There is a comminuted fracture of the talus, which extends from the anterior medial talar dome obliquely through the talar neck anterolaterally and posterior medially. Small loose bodies are present within the anterior joint space as well as within the lateral joint space and medial joint space. Ankle joint and subtalar joint effusions are present. There is diffuse soft tissue swelling.

4 DIAGNOSIS: Comminuted, minimally displaced talar neck fracture Minimally displaced and minimally angulated left distal third Salter Harris 2 tibia fracture INITIAL TREATMENT: Long leg posterior leg splint with stir up support Non weight bearing, elevation, pain control NPO and surgical referral made DEFINITIVE SURGICAL TREATMENT: Open reduction internal fixation of comminuted minimally displaced talus fracture with screw fixation. Loose body removal. OUTCOME: Immediate post op outcome without complications Sent home in non weight bearing short leg cast for 4 weeks

5 One week post op follow up alignment check: Improved on follow up visits with excellent bone healing on x rays At 4 weeks: Began weight bearing with walking boot and gentle PT out of boot

6 At 6 weeks: Initial weight bearing with CAM walking boot and plan to advance to PT for strengthening in four weeks DISCUSSION: Talar fractures are rare in children, especially those who are skeletally immature. Mean age is 10 15, and incidence is %. Fractures of the talus in both adults and children most commonly involve the talar neck. The most common mechanism of injury usually involves landing in dorsiflexion with a high axial loading force. Typically patients present after a fall or landing that transmits a high axial force through the talus. These injuries are seen most commonly after jumps/falls from height, during snow sports, and in car accidents. Patients will present with large joint effusions, an inability to weight bear, and significant tenderness with palpation or with any ankle range of motion. After a thorough history and physical exam, diagnostic evaluation typically begins with three view radiographs of the ankle. When there is suspicion of a talus fracture further diagnostic imaging with CT or MRI is warranted to help classify the fracture. Weight bearing or stress views to assess ankle joint stability are usually not obtained given patients absolute inability to weight bear and risk of fracture displacement. The Hawkins classifications (see below) are commonly used to classify severity of talar neck fractures and help determine prognosis and management. Given the high risk of complications even with very minimally displaced talar fractures, accurate CT images and classification are necessary to assess the need for surgical intervention. In general, older patients, more displaced fractures, and Hawkins class 3 and 4 fractures are highest risk for complications

7 including posttraumatic avascular necrosis, arthrosis, nonunion or delayed union, and neuropraxia. Smith et al reviewed complications of talus fractures in children and found that of twenty nine children who sustained a major fracture of the talar body, neck, or head requiring surgical intervention, avascular necrosis occurred in 2 patients (7%), arthrosis in 5 (17%), delayed union in 1 (3%), neuropraxia in 2 (7%), and infection in 0. There was need for further surgery in 3 (10%). Both high energy mechanism and fracture displacement corresponded to a greater number of posttraumatic complications. The number and severity of talus fractures was greater in older children. Initial management of such fractures includes non weight bearing immobilization to prevent any further displacement followed by CT scan. Initial immobilization will most likely require splinting given the high degree of swelling associated with talus fractures. Casting can usually be performed in 3 5 days after the swelling has reduced. Non operative management can be used in cases where the fracture is minimally displaced or non displaced. The patient will need to remain immobilized and non weight bearing for 6 8 weeks depending on nature of the fracture. All previous reports concerning talar fractures of all types recommend early active exercise without weight bearing, which can reduce the incidence of disuse atrophy and contractures. Early physical therapy and ROM exercises are essential once the fracture is stable and the patient can tolerate them without significant pain. Gentle ROM therapy can usually begin as early as 4 weeks after injury. Given the inter articular nature of talus fractures, good anatomical reduction with preservation of the blood supply is essential to prevent complications of arthrosis and AVN. Surgical fixation typically involves open reduction and internal screw fixation with removal of any loose bodies and bone grafting when necessary. When there is evidence of appropriate bone healing hardware removal is usually recommended, typically at around 12 weeks. Hawkins Classification of talar neck fractures: Type Description Treatment Complication risk Type 1 Non displaced fracture without dislocation Short leg cast w/ foot in slight equines for 8 weeks 10% Avascular Necrosis 4 weeks NWB 4 weeks WB Type 2 Displaced fracture of the talar neck with subluxation or dislocation of subtalar Closed reduction followed by casting 8 12 weeks. ORIF if more than % Avascular Necrosis

8 joint mm of dorsal displacement or any rotational deformity Type 3 Displaced fracture of talar neck w/ dislocation of body of talus from both subtalar joint and the ankle joint Requires ORIF due to disruption of the Talocalcaneal ligament 90% Avascular Necrosis Type 4 Talar neck fracture w/ dislocation of the head fragment: subtalar, tibiotalar, and talonavicular joint subluxation or dislocation Salvage surgical procedure with methylmethacrylate spacer placement *Open Type 4 fractures have 30% risk of infection *Adapted from Wheeless Textbook of Orthopedics References: 1. Smith, JT et al. Complications of Talus Fractures in Children. Journal of Pediatric Orthopaedics:December 2010 Volume 30 Issue 8 p Thordarson DB. Talar body fractures. Foot Ankle Trauma 2001; 32: Vallier HA, Nork SE, Benirschke SK, Sangeorzan BJ. Surgical treatment of talar body fractures. J Bone Joint Surg 2003; 85 A: Wheeless, CR III. Wheeless Textbook of Orthopedics.

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