Abstract
Case
Talar neck fractures are uncommon injuries associated with a high risk of avascular necrosis (AVN), particularly when accompanied by open fracture-dislocation and associated ankle fractures. Hawkins type IV injuries represent the most severe form and are associated with reported AVN rates of up to 100%. We report a rare case of a Hawkins and Canale type IV open talar neck fracture-dislocation with concomitant bimalleolar ankle fracture and lateral talar process fracture that achieved a favorable long-term outcome.
A 66-year-old man sustained a Hawkins and Canale type IV open talar neck fracture-dislocation with a bimalleolar ankle fracture and a lateral talar process fracture after a fall from a ladder. The talus was completely dislocated from the tibiotalar, subtalar, and talonavicular joints. Emergent irrigation, debridement, and external fixation were performed, followed by internal fixation 8 days after injury. Magnetic resonance imaging(MRI) at 1 year showed no talar necrosis, and radiographs at 7 years demonstrated no collapse.
Conclusion
Even in high-risk open talar fracture-dislocations, favorable long-term outcomes may be achieved through timely reduction and staged surgical management with an emphasis on soft-tissue preservation.
Introduction
Talar neck and body fractures are rare, accounting for less than 0.1% to 0.85% of all fractures, and typically result from high-energy trauma. , Because the talus is extensively covered by hyaline cartilage and has a limited vascular supply, these fractures carry a substantial risk of avascular necrosis (AVN). The overall incidence of AVN after talar neck and body fractures is approximately 40%. Hawkins type IV fractures, in particular, have reported AVN rates of 55% to 100%. , The risk is further increased in open fractures, fracture-dislocations, and cases accompanied by ankle fractures. ,, Talar fracture-dislocations with concomitant bimalleolar ankle fractures are exceedingly uncommon, especially when complicated by open injuries. We report a case of a Hawkins type IV open talar fracture-dislocation with associated bimalleolar ankle fracture and lateral talar process fracture. Despite the extremely high risk of AVN, early reduction and staged surgical management emphasizing infection control and soft-tissue preservation resulted in a favorable long-term outcome.
The patient provided informed consent for publication of this case.
Case report
A 66-year-old man with no significant medical history presented after twisting his right ankle during a fall from a ladder. On arrival, a 10 cm open wound was observed on the inferomedial ankle with exposure of the talar dome ( Fig. 1 ). Although the injury occurred outdoors, no gross soil contamination was noted. Active toe motion was limited, but distal perfusion was intact, with normal capillary refill and palpable dorsalis pedis and posterior tibial pulses confirmed by Doppler.
Clinical photograph and radiographs at presentation.
(A, B) Clinical photographs showing an approximately 10 cm open wound on the inferomedial aspect of the right ankle, with exposure of the talar dome.
(C) Anteroposterior and (D) lateral radiographs demonstrating severe disruption of ankle alignment with marked deformity.
Radiographs and computed tomography (CT) revealed an open talar neck fracture, distal fibular fracture, medial malleolar fracture, and lateral talar process fracture, with complete dislocation of the talus from the tibiotalar, subtalar, and talonavicular joints ( Figs. 1 and 2 ). The injury was classified as a Gustilo-Anderson type IIIA open fracture and a Hawkins and Canale type IV talar fracture-dislocation.
Computed tomography(CT) images at presentation.
(A) Coronal CT image demonstrating dislocation of the tibiotalar and subtalar joints. White arrows indicate the tibiotalar articular surface of the talus; black arrows indicate the subtalar articular surface of the talus. The white arrowhead indicates a distal fibular fragment.
(B) Sagittal CT image showing posteromedial displacement of the tibiotalar articular surface (white arrows).
(C) Subtalar joint dislocation (black arrows).
(D) Comminuted fracture of the medial malleolus (black arrows).
(E) Fracture of the lateral malleolus with a distal fibular fragment (black arrows).
(F) Talonavicular joint dislocation (black arrow).
Emergent irrigation, debridement, and ankle-spanning external fixation were performed ( Fig. 3 ). Pulse lavage with 6,000 mL of normal saline was used, and intravenous ampicillin/sulbactam (9.0 g/day) was administered for seven days.
Radiographs and computed tomography(CT) images after application of an external fixator.
Postoperative radiographs and CT images obtained immediately after external fixation, demonstrating reduction of the dislocation. External fixation pins were inserted into the tibia and calcaneus.
(A) Anteroposterior radiograph.
(B) Lateral radiograph.
(C) Coronal CT image.
(D) Sagittal CT image.
After soft-tissue swelling improved, open reduction and internal fixation were performed on hospital day eight. The medial malleolus was stabilized with cerclage wiring, while the lateral malleolus was fixed with a distal fibular plate. The talus, fractured into three segments, was stabilized using two medial cannulated screws and a lateral screw-plate construct ( Fig. 4 ).
