Closed peritalar dislocation (CPD) refers to the simultaneous dislocation of the subtalar and talonavicular joints, which is a rare and severe in foot and ankle trauma, accounting for <1% of all talar dislocations. ^, It is usually caused by high-energy impacts, such as falls from height, traffic accidents or sports injuries, and is often accompanied by multiple fractures and soft tissue injuries. This review will focus on both medial and lateral peritalar dislocations, encompassing subtalar joint (STJ) and talonavicular joint (TNJ) involvement. The presence of navicular and calcaneal sustentaculum tali fractures complicates the injury due to their roles in foot stability.

Limited literature exists on this combined injury pattern, making diagnosis and treatment challenging. ^,, This study presents a CPD case with associated fractures treated at our hospital and reviews related literature.

A 34-year-old male manual labour fell from a height of 7 m while working, landing on his left foot. Immediately after the injury, he experienced severe pain in the left foot and ankle and was unable to stand or walk. He did not receive active treatment such as reduction or immobilization at the local clinic. Three days later, due to persistent severe pain and aggravated swelling, he was transferred to our hospital for further treatment.

The patient was admitted and underwent systematic evaluation, which ruled out injuries to the cranium, spinal cord, thorax, abdomen, and pelvis. Furthermore, no other fractures or dislocations including tibial plateau fracture, cervical/thoracic/lumbar vertebral fractures, pelvic fracture, acetabular fracture, or skull base fracture were identified beyond the documented left foot and ankle. However, multiple areas of cutaneous ecchymosis and contusion were evident on physical examination. At the time of injury, the patient experienced a brief loss of consciousness, which did not exceed 30 min in duration.

The left foot and ankle were significantly swollen, with ecchymosis around the ankle and hindfoot. Multiple severe hemorrhagic blisters were present on the skin, predominantly over the hindfoot and dorsum of the foot. The foot arch were obviously collapsed, and the height of the foot was significantly reduced. There was severe tenderness in the ankle, hindfoot and midfoot areas, and active and passive movements of the ankle and subtalar joints were severely limited due to pain. The sensation of the plantar and dorsal surfaces of the left foot was normal, and the dorsalis pedis and posterior tibial pulses were palpable. Special attention was paid to the signs of foot compartment syndrome; although the swelling was severe with haemorrhagic blisters, the toes remained supple, and there was no excruciating pain on passive stretch of the intrinsic muscles, ruling out acute compartment syndrome at the time of admission.

Initial lateral radiography of the ankle (non-weight-bearing position) showed no obvious fractures of the talus, but there were signs of plantar dislocation of the talonavicular and talocalcaneal joints ( Fig. 1 ). To further clarify the injury pattern, 3D-CT examination was performed, which revealed a fracture of the anterior lateral wall of the calcaneus, a fracture of the base of the fifth metatarsal, a fracture of the calcaneal sustentaculum tali, a fracture of the navicular bone, and complete plantar displacement of the talus. There was no significant dislocation of the calcaneocuboid joint ( Figs. 2–4 ).

A show the lateral radiograph of the ankle demonstrating complete loss of apposition in the subtalar, talonavicular joints (peritalar dislocation). fracture of the base of the fifth metatarsal, and fracture of the sustentaculum tali with no obvious fractures of the talus.

B show the medial-to-lateral view 3D-CT of the ankle showing a fracture of the calcaneal sustentaculum tali and calcaneal medical wall, as well as a fracture of the navicular and plantar dislocation of the talonavicular joint.

C show the AP view 3D-CT demonstrating a longitudinal split fracture of the lateral one-third of the navicular.

D show the lateral-to-medial view 3D-CT of the ankle revealing a fracture of the anterior lateral wall of the calcaneus, the base of the fifth metatarsal and fibula distal tip fracture, with no significant dislocation of the calcaneocuboid joint.

Intraoperative images are presented as follows: A illustrates the dislocation of the scaphoid bone, B demonstrates its reduction, and C depicts the fixation using an X-shaped steel plate.

A show the ankle one day post-surgery. B at three months, remove the two Kirschner wires used to stabilize the calcaneus, talus, and tibia. C at six months, the plate’s proximal lateral screw for the trans talonavicular joint fixation broke.

A and E show the ankle one day post-surgery. B and F at three months, remove the two Kirschner wires used to stabilize the calcaneus, talus, and tibia. C and G at six months, the plate’s proximal lateral screw for the trans talonavicular joint fixation broke. D and H at 2-year final postoperative follow-up.

Three days after the injury, significant swelling and haemorrhagic blisters prevented safe open reduction. With the elapsed ischemic time, we faced a dilemma between urgent reduction and the risk of wound complications. We opted for a closed reduction under sedation as a temporizing measure to restore alignment and relieve pressure on the soft tissues. We then monitored for compartment syndrome while optimizing the soft tissue envelope. Fig. 5

3D CT imaging at the 2-year final postoperative follow-up: A shows the AP view, B the medial-to-lateral view, and C the lateral-to-medial view. Did not reveal significant talar collapse or subchondral sclerosis.

After completing the preoperative examination and evaluating the patient’s general condition, surgical treatment was performed under general anaesthesia 14 days after the injury. We selected direct open reduction over the use of an external fixator, even though the latter is typically recommended for severe soft tissue compromise in complex foot dislocations. This decision was further influenced by the significant instability of the multi-joint dislocation and the critical requirement for anatomical restoration of the medial column. During the surgical procedure, we emphasized meticulous soft tissue management by employing minimal-tension closure techniques and delaying the incision until the appearance of the ‘wrinkle sign,’ thereby mitigating the necessity for potentially expensive staged surgeries.( Fig. 3 ).

The surgical approach was selected according to the fracture and dislocation site: a lateral incision was made to expose the calcaneal fracture, the base of the fifth metatarsal fracture, a medial incision was made to expose the sustentaculum tali fracture, and a dorsal incision was made to expose the navicular fracture. First, the dislocated talus was reset under direct vision, and then the fractures of the navicular, sustentaculum tali, calcaneus and fifth metatarsal were reset sequentially. Kirschner wires were introduced from the plantar aspect into the tibia to achieve temporary trans-articular stabilization of the ankle and subtalar joints, given that fixation limited to the talus is insufficient for maintaining the axial alignment of the ankle joint. The associated fractures were then definitively fixed with Kirschner wires and plates as appropriate to ensure multi-column stability. Intraoperative fluoroscopy confirmed that the fracture reduction and joint alignment were satisfactory.

Postoperatively, the left lower limb was elevated, and antibiotics were routinely used to prevent infection. Analgesics were administered to relieve pain, and ice compress was applied to reduce swelling. The Kirschner wires were removed 4 weeks after operation, and a short leg splint was applied for external fixation for another 6 weeks. The patient was strictly advised to maintain non-weight-bearing status for the first 3 months postoperatively to protect the trans-articular fixation and prevent hardware fatigue or failure during early bone healing. Under the guidance of the physical therapist, the patient performed ankle flexion and extension exercises to promote joint function recovery. Partial weight-bearing with a short leg splint is recommended for two weeks, followed by progressive weight-bearing with the short leg splint for an additional two weeks, until full weight-bearing is achieved without the use of the short leg splint.

Weight-bearing ambulation commenced 3 months postoperatively, followed by a gradual resumption of daily activities and occupational duties. the patient’s left foot and ankle swelling had completely subsided, and the surgical incisions healed well without complications such as infection, skin necrosis or neurovascular injury. The patient experienced persistent dull pain in the affected foot during weight-bearing activities until 6 months postoperatively, at which point the discomfort subsided to a mild level.

During the follow-up period, routine radiography at 6 months postoperatively revealed a fatigue fracture of the proximal lateral screw of the plate used for trans-talonavicular joint fixation. This hardware failure occurred after the patient had commenced partial weight-bearing. However, there was no evidence of loss of reduction or joint instability, and the patient did not report any associated pain or discomfort. Consequently, no secondary surgical intervention was required. By the 9-month mark, as the fractures had achieved clinical and radiological union, the remaining internal fixation was removed as planned.

At the 2-year follow-up, the ankle range of motion (ROM) was measured. Compared with the contralateral side, inversion and eversion were restricted to 10 degrees (approximately 40% of the normal side), while dorsiflexion and plantarflexion were limited to a total arc of 45 degrees, representing a reduction of approximately 50% in overall sagittal plane mobility. The functional outcome was satisfactory but reflected the severity of the injury, with an AOFAS score of 80 points, accounting for the restricted range of motion and residual mild activity-related pain.

Closed peritalar dislocation (CPD) refers to the simultaneous dislocation of the subtalar and talonavicular joints, which is a rare and severe foot and ankle trauma, accounting for <1% of all talar dislocations. ^, It is usually caused by high-energy impacts such as falls from height, traffic accidents or sports injuries, and is often accompanied by multiple fractures and soft tissue injuries, which aligns with the injury mechanism of the patient in this case (a 7-meter fall).

Imaging is essential for diagnosing this complex injury. Plain radiography can identify joint dislocation and major fractures but often overlooks small fragment displacement and articular surface involvement. 3D-CT offers advantages of clear imaging, multi-angle reconstruction, and accurate visualization of bone structures. It enables comprehensive assessment of fracture type and displacement, degree of joint dislocation, and articular surface damage, providing a critical basis for formulating surgical plans. ^, In this case, plain radiography only showed joint dislocation, while 3D-CT clearly identified fractures of the navicular, sustentaculum tali, anterior lateral wall of the calcaneus, and base of the fifth metatarsal, confirming the diagnosis and guiding the surgical approach and fixation method.

The treatment principle for CPD with multiple fractures is to promptly restore the anatomical alignment of joints and fractures, stabilize the joint, and protect the blood supply of the talus and surrounding soft tissues to maximize limb function recovery. ^, Closed reduction is only suitable for a few simple dislocations without obvious fractures or soft tissue entrapment. For dislocations combined with multiple fractures, open reduction is typically required to directly reduce fractures and dislocations, followed by internal fixation to maintain stability. In this case, we adopted open reduction and internal fixation: first reducing the dislocated talus, then fixing fractures of the navicular, sustentaculum tali, and other sites, and using Kirschner wires to fix the ankle and subtalar joints. This effectively restored the anatomical structure and stability of the joint, laying the foundation for functional recovery.

Postoperative rehabilitation is an integral part of treatment. Reasonable rehabilitation training can promote joint function recovery and prevent complications such as joint stiffness and muscle atrophy. In this case, the patient was advised to maintain non-weight-bearing for 3 months postoperatively to avoid premature load bearing leading to fracture displacement or joint instability. Subsequently, under the guidance of a physical therapist, gradual weight-bearing training and joint functional exercises were performed, achieving satisfactory results.

In clinical practice, missed or delayed diagnosis of peritalar injuries, including peritalar dislocation and associated fractures, often leads to functional impairment due to their subtle radiographic findings and low incidence. Clinicians should maintain a high degree of suspicion for such injuries in patients with high-energy trauma, especially when pain and physical examination findings are disproportionate to the initial diagnosis. Timely application of advanced imaging techniques such as 3D-CT is crucial for improving diagnostic accuracy. Additionally, individualized treatment plans based on injury severity and patient conditions, combined with standardized postoperative rehabilitation, are key to improving prognosis.

Furthermore, the timing of intervention is a critical factor in the prognosis of peritalar dislocations. CPD should be managed as a ‘time-sensitive’ emergency, like a dislocated knee or a mangled limb. The primary goal is the immediate restoration of the talar blood supply and the decompression of the foot’s osteofascial compartments. In this case, the patient’s treatment was delayed for 3 days before reaching our facility. Such a delay significantly escalates the risk of foot compartment syndrome, where rising interstitial pressure can lead to intrinsic muscle necrosis and permanent claw-toe deformities. While the absence of compartment syndrome in this patient was fortunate, clinicians must maintain a high index of suspicion and be prepared to perform emergent fasciotomies alongside reduction.

While CPD is typically associated with talar neck or calcaneal body fractures, the specific involvement of both the navicular and the sustentaculum tali creates a ‘double-pillar’ instability of the medial column ( Table 1 ). This case demonstrates that even in a delayed setting (14 days post-injury) and without external fixation, anatomical restoration of these specific structures using a dual-incision approach can achieve mid-term stability and prevent collapse of the medial longitudinal arch

Table 1

Study and patient characteristics ^a .

Talar Fracture	Dislocation Joint			Remark	Author	Journal	Year
	Tibiotalar	Talocalcaneal	Talonavicular
O	X	O	O		Ibrahim Saeed Ibrahim	Trauma Case Rep	2024
O	O	O	X		Joshua Eskew	BMJ Case Rep	2024
O	X	O	O		Fernanda Critelli	J Orthop Case Rep	2024
O	X	O	X		Montassar El Ayachi	Int J Surg Case Rep	2024
O	X	O	X		Fitzgerald C Anazor	Br J Hosp Med (Lond)	2023
O	X	O	O		Seyed Ali Hashemi	Int J Surg Case Rep	2023
O	O	O	X		Firas Kawtharani [12]	J Orthop Case Rep	2023
X	O	X	X		Constantinos Chaniotakis [13]	Cureus	2023
O	X	O	O		Aamir Bin Sabir [14]	Int J Burns Trauma	2023
X	O	X	X		Walid Bouziane [15]	Int J Surg Case Rep	2022
O	X	O	O		Hanna Sikora [16]	Ortop Traumatol Rehabil	2022
X	O	O	O		Mohammad Jesan Khan [17]	Int J Burns Trauma	2022
O	X	X	O		Amr Selim [18]	Medicine (Baltimore)	2022
O	X	X	O		Kyle E Wamelink [19]	J Am Podiatr Med Assoc	2022
X	O	X	O		Yusuke Eda [20]	Trauma Case Rep	2021
O	X	O	X		Carlo Biz [21]	BMC Musculoskelet Disord	2019
O	O	O	X		Ahmad M Radaideh [22]	Am J Case Rep	2018
O	X	O	O		Benjamin Yglesias [23]	J Surg Case Rep	2018
O	X	O	X		R Gérard [24]	Orthop Traumatol Surg Res	2017
O	X	O	O		Haijiao Mao [25]	Injury	2015
X	X	O	O		Mohamed Azarkane [26]	J Med Case Rep	2014
O	O	X	X		Nicholas D Clement [27]	J Orthop Surg Res	2010
O	X	O	O		J B Seeger [28]	Unfallchirurg	2009
O	X	O	X		Elias Fotiadis [29]	Cases J	2009
X	O	X	X		Nitish Gogi [30]	Foot Ankle Surg	2008
X	X	O	O		John Harris [31]	J Foot Ankle Surg	2008
O	X	O	X		L de Palma [32]	Arch Orthop Trauma Surg	2008
O	X	O	X		Ozcan Pehlivan [33]	Arch Orthop Trauma Surg	2002
O	X	X	O		M A Hafez [34]	Foot Ankle Int	2000
O	O	O	X	left closed	Gopisankar Balaji G [35]	BMJ Case Rep	2014
X	X	O	X	3 cases	Luigi de Palma [36]	Foot Ankle Int	2008

Only gold members can continue reading. Log In or Register to continue

Share this:

• Click to share on Twitter (Opens in new window)
• Click to share on Facebook (Opens in new window)

Related

Related posts:

Exploring the Shoulder Lateral Epicondylitis Femoral Acetabular Impingement and Labral Tears 30 Achilles Tendon Repair Articular Cartilage Biology, Osteoarthritis, Biologics, and Stem Cell Therapy Foot and Ankle Anatomy and Biomechanics

Stay updated, free articles. Join our Telegram channel

Join