26-year-old man with ankle pain, swelling after victory leap over tennis net
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A 26-year-old man hurdled over a tennis net to celebrate winning a match. He landed awkwardly on the lateral edge of his right foot, felt a pop and noted immediate pain and swelling as he collapsed onto the court.
Unable to support his weight, the man was helped off the court and taken to the ED. He has no past medical history, takes no medications and is a non-smoker.
Source: Ian Savage-Elliott, MD
On exam, he was alert and oriented. His right ankle and foot were swollen and tender to palpation with palpable crepitus, and a mass was appreciated over the dorsum of the foot. He was neurovascularly intact and unable to weight-bear on the right extremity.
What injuries should be suspected in this young athlete?
Common injuries in an athlete after an incident like this would include an incomplete or complete lateral ligament ankle sprain, ankle fracture or rupture of the Achilles tendon. Imaging was significant for a Hawkins 4 talar neck fracture with displacement of the anterior fragment (Figure 1).
What next steps should be taken?
See answer below.
Open reduction and internal fixation of talar fragment
The day of his injury, the patient was taken for closed vs. open reduction and external fixation of the right lower extremity. Intraoperatively, the fragment was unable to be reduced in a closed fashion secondary to partial extrusion of the distal fragment and, therefore, open reduction was required. An anterolateral incision was made in line with the base of the fourth metatarsal. The extensor retinaculum was encountered, which had suffered significant trauma and the extruded talar fragment was visualized (Figure 2). We preserved the rest of the extensor retinaculum and the extensor digitorum was retracted medially. Reduction of the talar fragment was achieved via use of a Weber clamp, which was placed on the navicular to facilitate ultimate reduction of the talus, a Steinman pin placed through the talar fragment and axial traction performed through the calcaneal pin. After reduction was completed, the retinaculum was repaired and the incision was closed using Monocryl (Ethicon) and nylon sutures. Final reduction films and CT cuts were made after external fixation was done (Figure 3).
Surgical timing/approach
The patient was discharged from the hospital on postoperative day 2. He was followed up in clinic 1 week later, at which time his skin was wrinkled and his swelling appeared appropriate for surgery. A discussion was had with the patient with regard to his surgical options. These included definitive treatment in an external fixator, open reduction and internal fixation (ORIF), subtalar fusion and tibiotalocalcaneal fusion. Given his young age and high activity level, the patient elected for ORIF.
Operative technique
We employed a two-incision technique that involved the anterolateral incision we previously made and a 6-cm anteromedial incision. We elevated the saphenous vein and then made a capsulotomy. We accessed the posteromedial aspect of the joint through the longitudinal split in the fracture and were able to clear the joint of fracture debris and comminutia. We reduced the fracture with percutaneous K-wires working anteromedial to posterolateral immediately adjacent to the navicular. The dome fragment was reduced using K-wires working anterolateral to posteromedial. These K-wires were then replaced by partially threaded cannulated screws (Figure 4). Next, we used a locking plate on the lateral side to stabilize the construct. With the procedure completed, we removed the external fixator and closed the incisions with Monocryl and nylon sutures and took final films (Figure 5).
The patient was splinted for the first 6 weeks postoperatively. Afterward, he transitioned to a controlled, ankle movement walker boot. At the last follow-up visit, which took place about 5 months after surgery, his incisions were healed and he was weight-bearing without an assistance device. He had 10° dorsiflexion and 50° plantarflexion with no blocks to motion. The patient was working with physical therapy to alleviate his ankle stiffness and hoped to resume playing tennis in the future. Five-month radiographs are shown (Figure 6), as well as clinical photos of his foot (Figure 7).
Discussion
Although one prominent athlete recently sustained a talus fracture, these injuries are somewhat rare in athletes. When they do occur, they are associated with numerous complications, most commonly post-traumatic arthritis given the talar articulations with the tibia, medial malleolus, distal fibula, navicular and three facets of the calcaneus. Most of the research on talus fractures are level-4 studies with a paucity of high-quality data available. The Hawkins classification provides both descriptive and prognostic details on talar neck fractures with associated joint dislocations and can be used to estimate postoperative osteonecrosis and outcomes, both of which worsen with increased Hawkins grade, according to research by John A. Buza III, MD, and colleagues. Hawkins is also credited with the development of the Hawkins sign or the presence of subchondral atrophy in the talar dome that implies the vascular supply to the area is intact at 6 to 8 weeks after injury.
Lateral process fractures of the talus have a known association with snowboarding and represent as much as 34% of all ankle fractures sustained while snowboarding. The mechanism of injury is believed to be forcible eversion of a dorsiflexed foot while riding toeside. Stress fractures of the talus also have been previously documented in the literature but are rare occurrences. Unlike the typical ankle fracture, these injuries often require staged procedures and orthopedic intervention on a more urgent basis. Dual anteromedial and anterolateral surgical exposures are typically recommended to optimize access to the talar neck and anterior body, but this may increase the risk for osteonecrosis. Technical consideration should be given to minimizing dissection on the inferior aspect of the talar neck and the deltoid medially. Multiple studies have found no difference in outcomes following use of screws alone vs. screw-plate constructs, although plates can be helpful in the presence of medial and/or lateral comminutia. While the older literature viewed urgent reduction and fixation as paramount to avoiding osteonecrosis, newer studies have not validated this research and timing of fixation should be based on soft tissues, which is generally 1 to 3 weeks following injury. Restoration of axial and articular alignment while minimizing soft tissue damage and protecting the blood supply are paramount to a good outcome. Poor outcome and osteonecrosis generally increase with increasing Hawkins type.
The prevalence of post-traumatic arthritis, which occurs in up to 100% of patients who sustain a Hawkins 4 type injury, remains a serious problem, particularly in athletes. Current treatments include tibiotalar and subtalar arthrodesis, as well as total ankle replacement or total talus replacement. However, return to sport at the same level of play as preinjury level following any of these treatments has not been well documented in the literature.
Here, we present the unique case of a Hawkins 4 fracture dislocation injury in a young, healthy, athletic patient who sustained it during tennis and was treated via a staged procedure with reasonable short-term results. It is important to note these are difficult injuries secondary to the precarious blood supply and difficulty with osteonecrosis and post-traumatic arthritis. Further study into the long-term outcomes of these injuries is warranted, particularly in the athletic population.
- References:
- Hawkins LG. J Bone Joint Surg Am. 52;1970:991-1002.
- Kirkpatrick DP, et al. Am J Sports Med. 1998;doi:10.1177/03635465980260021901.
- Vallier H. J Orthop Trauma. 2015;doi:10.1097/BOT.0000000000000378.
- For more information:
- Ramon F. Rodriguez, MD, can be reached at 1415 Tulane Ave., New Orleans, LA 70112; email: rrodri1@tulane.edu.
- Austin J. Ross, BS, a medical student at Tulane University School of Medicine, can be reached at 1430 Tulane Ave., New Orleans, LA 70112; email: aross12@tulane.edu.
- Ian Savage-Elliott, MD, can be reached at Tulane University School of Medicine, 1415 Tulane Ave., New Orleans, LA 70112; email: ielliott@tulane.edu.
- Edited by Travis Frantz, MD, and Ian Savage-Elliott, MD. Frantz is a sports medicine and shoulder fellow at TRIA Orthopaedic Center in Minneapolis. He completed his orthopedic surgery residency at The Ohio State University Wexner Medical Center in Columbus, Ohio. Savage-Elliott is a chief resident in the department of orthopedic surgery at Tulane University Medical Center in New Orleans. He will pursue fellowship training in foot and ankle and sports medicine following residency completion. For information on submitting Orthopedics Today Grand Rounds cases, please email: orthopedics@healio.com.
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Buza JA, et al. Foot Ankle Surg. 2018;doi:10.1016/j.fas.2017.04.008.
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