Please rate topic.
Average 4.2 of 51 Ratings
Which of the following is true when comparing Figure A to Figure B?
Figure B is more likely to have an associated fracture
Figure A is more likely to be blocked from closed reduction by the extensor digitorum brevis
FIgure A is more likely to be open
FIgure B is more likely to be blocked from closed reduction by the posterior tibial tendon
Figure A more likely to be stable following closed reduction
Select Answer to see Preferred Response
While medial subtalar dislocations (Figure B) are more common, lateral subtalar dislocations (Figure A) are more likely to be open and have associated fractures.
Subtalar dislocations are devastating injuries with high rates of subtalar arthritis. Medial dislocations are more common and are occasionally blocked from closed reduction by the extensor digitorum brevis. Lateral dislocations are more likely to be open, have an associated fracture, and are occasionally blocked from closed reduction by the posterior tibial tendon, flexor digitorum longus, or flexor hallucis longus. Despite these differences, the injuries are treated similarly with closed reduction and immobilization followed by range-of-motion exercises.
DeLee et al. review 17 cases of subtalar dislocations. They found worse long-term results with lateral subtalar dislocations secondary to associated fractures and frequency of open injuries. They recommend cast immobilization for three weeks followed by early motion.
Heppenstall et al. review 20 cases of subtalar dislocations. They maintained reduction in a short-leg cast for 6 weeks following the injury and had 14 excellent results. The most common complications were restriction of motion and radiographic evidence of degenerative changes.
Goldner et al. review the long-term results of 15 patients who sustained a type III, open, subtalar dislocation. In contrast to closed injuries, they found that open subtalar dislocations are more likely to develop osteonecrosis of the talar body requiring pantalar arthrodesis.
Figure A shows a lateral subtalar dislocation. Figure B shows a medial subtalar dislocation.
Answer 1: Lateral subtalar dislocations are more likely to have associated fractures.
Answer 2: Lateral subtalar dislocations are most commonly blocked from closed reduction by the posterior tibial tendon.
Answer 4: Medial subtalar dislocations are more commonly blocked from closed reduction by the extensor digitorum brevis.
Answer 5: Medial subtalar dislocations are more likely to be stable, likely secondary to a decreased rate of associated fractures.
DeLee JC, Curtis R.
J Bone Joint Surg Am. 1982 Mar;64(3):433-7. PMID: 7061560 (Link to Abstract)
DeLee, JBJS 1982
Heppenstall RB, Farahvar H, Balderston R, Lotke P.
J Trauma. 1980 Jun;20(6):494-7. PMID: 7373681 (Link to Abstract)
Heppenstall, JTACS 1980
Goldner JL, Poletti SC, Gates HS, Richardson WJ
J Bone Joint Surg Am. 1995 Jul;77(7):1075-9. PMID: 7608231 (Link to Abstract)
Goldner, JBJS 1995
Please rate question.
Average 4.0 of 32 Ratings
A 34-year-old male falls 10 feet from a balcony and is brought to the emergency room with the deformity seen in Figure A. Radiographs shown are shown in Figure B and C. Which of the following structures can block closed reduction of this injury pattern?
Flexor hallucis longus tendon
Extensor digitorum brevis muscle
Posterior tibial tendon
Tibialis anterior tendon
Figures A through C show a medial subtalar dislocation. Irreducible dislocations are typically the result of either inadequate sedation or interposed soft tissue structures.
In medial dislocations, the extensor digitorum brevis, the deep peroneal neurovascular bundle, or the joint capsule may block a closed reduction. In lateral dislocations, the most common structure implicated as a block to reduction is the posterior tibial tendon, although the flexor digitorum longs, posterior tibial neurovascular bundle or flexor hallucis may also block reduction.
Bibbo et al found that subtalar dislocations were irreducible 32% of the time and that 88% had ipsilateral foot and ankle injuries. At follow up, 89% of patients demonstrated radiographic changes of the subtalar joint, and had worse function on the side of the subtalar dislocation as demonstrated by lower AOFAS scores.
Answer 1. The flexor hallucis longus tendon may be a block to closed reduction for lateral subtalar dislocations
Answer 3. The posterior tibial tendon may be a block to reduction for lateral subtalar dislocations
Answer 4. The tibialis anterior tendon does not commonly preclude closed reduction of a subtalar dislocation
Answer 5. The plantar fascia does not block closed reduction of the subtalar joint
Bibbo C, Anderson RB, Davis WH
Foot Ankle Int. 2003 Feb;24(2):158-63. PMID: 12627624 (Link to Abstract)
Bibbo, FAI 2003
Average 4.0 of 42 Ratings
A 37-year-old female sustains the injury seen in Figures A and B. At long-term follow up, degeneration of which of the following joints has been shown to have the highest rate of patient symptoms?
Figures A and B show a medial subtalar dislocation, which is more common than a lateral dislocation (65% vs. 35%).
The referenced article by Bibbo et al looked at long-term follow up of these patients, and noted that radiographic degeneration of the ankle and subtalar joints were 89%, although 31% of ankle joints were symptomatic and 68% of subtalar joints were symptomatic. Midfoot degeneration was seen radiographically in 72% (15% symptomatic).
Average 2.0 of 29 Ratings
A 30-year-old male falls off the roof and sustains the injury seen in Figure A. Multiple attempts at a closed reduction are made, but are unsuccessful. Entrapment of which of the following structures is the most likely etiology?
Anterior tibial tendon
Flexor hallucis longus
The radiograph shows a lateral subtalar dislocation with an associated talonavicular dislocation as well. Dislocations of the talonavicular are often seen with subtalar dislocations and one needs a high index of suspicion in order not to miss this associated injury.
Subtalar dislocations are associated with high energy, open(25%), and irreducible (33%) fractures. Lateral subtalar dislocations are thought to result from forceful eversion of a plantar-flexed foot, with the anterior process of the calcaneus acting as a fulcrum around which the anterolateral corner of the talus pivots. The reduction maneuver involves initial traction and foot hyperpronation, followed by supination for lateral dislocations.
Saltzman and Marsh present a review article about acute hindfoot dislocations and discuss their management and long term follow up. Lateral dislocations that are irreducible are blocked most commonly by the posterior tibialis tendon. The tendons of the FHL and FDL less commonly block reduction. These dislocations often require emergent open reductions, tendon relocation, and stabilization. Medial dislocations account for 65%, and reduction is often blocked by the extensor digitorum brevis. They are thought to be more common due to the strong buttress of the lateral malleolus.
Saltzman C, Marsh JL.
J Am Acad Orthop Surg. 1997 Jul;5(4):192-198. PMID: 10797221 (Link to Abstract)
Saltzman, JAAOS 1997
Average 4.0 of 21 Ratings
A 40-year-old male suffers the isolated injury shown in figure A with no associated fractures. What joint is dislocated in this radiograph?
The radiograph shows a subtalar (talocalcaneal) dislocation with a talonavicular dislocation as well. If subtalar dislocations also involve dislocation of the articulations at both the talonavicular and ankle (tibiotalar) joint, a talar extrusion is seen. Subtalar dislocations are associated with high energy, open (25%), and irreducible (33%) fractures. Medial dislocations account for 65%, and reduction is blocked by the extensor digitorum brevis (EDB). Lateral dislocations that are irreducible are blocked by the posterior tibialis, FHL, and FDL tendons. These dislocations often require emergent open reductions, tendon relocation, and stabilization.
Bibbo et al reported clinical and radiographic outcome on 25 patients and the majority of these patients had radiographic degenerative changes at 5 years follow up.
The review reference by Bohay and Manoli covers subtalar joint dislocations and notes the importance of anatomic reduction to achieve optimal outcomes.
Bohay DR, Manoli A 2nd.
Foot Ankle Int. 1995 Dec;16(12):803-8. PMID: 8749354 (Link to Abstract)
Bohay, FAI 1995
Average 3.0 of 44 Ratings
Dislocations Of The Talus Dr. Nabil Ebraheim
HPI - fall from height ( 3 feet). at presentation in ER we attempted to reduce peritalar dislocation in iv. sedation, and due to a relative anatomic position of the foot we assumed that it was fine (marked swelling). finally, at the Rx control we realized that instead of reducing the subtalar joint, we dislocated the tibio-talat joint
how would you describe this lesion?
HPI - 21 yo male, volleyball injury.
Closed reduced in OR.
CT scan post reveals posterior medial talus fracture.
How would you treat this patient?