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Excision of the 1 centimeter talar fragment shown in Figure A would lead to complete incompetence of which of the following structures?
Inferior peroneal retinaculum
Lateral talocalcaneal ligament
Posterior talofibular ligament
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Figure A shows a lateral process talar fracture. Excision of a fragment of approximately 1 cubic centimeter is reported for acute injury as well as painful nonunion/fibrous union. Excision of this piece is shown to sacrifice the entire lateral talocalcaneal ligament as well as 10% of the anterior and posterior talofibular ligaments.
Langer et al performed a cadaveric biomechanical analysis of such an excision and found that ankle and subtalar instability were not created with simple excision of this fragment.
DiGiovanni et al found that only three ligaments attach to the lateral process of the talus: lateral talocalcaneal, anterior talofibular, and posterior talofibular, with the lateral talocalcaneal ligament inserting closest to the tip/apex of the lateral process.
Illustration A shows an anatomical drawing of the ligaments of the lateral ankle. Illustration B shows a cadaveric image of the ligaments of the lateral ankle. The numbers in Illustration B correspond to the following structures: 1- calcaneofibular ligament, 2-lateral talocalcaneal ligament, 3-anterior talofibular ligament, 4-peroneal tubercle.
Langer P, Nickisch F, Spenciner D, Fleming B, DiGiovanni CW
Foot Ankle Int. 2007 Jan;28(1):78-83. PMID: 17257543 (Link to Abstract)
Langer, FAI 2007
DiGiovanni CW, Langer PR, Nickisch F, Spenciner D
Foot Ankle Int. 2007 Feb;28(2):175-80. PMID: 17296135 (Link to Abstract)
DiGiovanni, FAI 2007
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A 34-year-old male has persistent anterolateral ankle pain after a snowboarding injury 1 week ago and is unable to bear weight. Three good quality radiographic views of the ankle are negative for fracture or other abnormalities. What is the next best step in management?
Short leg cast application
MRI of ankle
Fractures of the lateral process of the talus are frequently overlooked and should always be considered in the differential diagnosis of ankle pain in snowboarders. The common mechanism for fracture is dorsiflexion of the ankle and eversion of the hindfoot.
The reference by Vlahovich et al is a case report of a talus fracture in a snowboarder and argues the importance of CT scans in evaluating these injuries as radiographs may fail to show the injury and amount of displacement and comminution of the fracture.
The reference by Tucker et al is a review of the literature which emphasized the importance of early diagnosis to avoid long term complications. They recommend short leg casting for nondisplaced fractures and surgery for displaced or comminuted fractures.
Vlahovich AT, Mehin R, O'Brien PJ
J Orthop Trauma. 2005 Aug;19(7):498-500. PMID: 16056086 (Link to Abstract)
Vlahovich, JOT 2005
Tucker DJ, Feder JM, Boylan JP.
Foot Ankle Int. 1998 Sep;19(9):641-6. PMID: 9763174 (Link to Abstract)
Tucker, FAI 1998
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Title: Visualization of Implant Failure Author: Thomas A. (Toney) Russell, MD...
Title: Talus Fractures: When and How to Fix Author: Steven Steinlauf, MD Durati...
HPI - MVA
What is the initial treatment?