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Introduction
  • Typically from a high-energy mechanism
    • 25% may be open 
      • lateral dislocations more likely to be open
    • 65% to 80% are medial dislocations
    • remaining are lateral dislocations
    • case reports of anterior or posterior dislocations
  • Associated injuries
    • associated dislocations 
      • talonavicular
    • associated fractures (up to 44%) 
      • with medial dislocation
        • dorsomedial talar head 
        • posterior process of talus  
        • navicular 
      • with lateral dislocation
        • cuboid 
        • anterior calcaneus 
        • lateral process of talus 
        • fibula 
Presentation
  • Physical exam
    • foot will be locked in supination with medial dislocation 
    • foot will be locked in pronation with lateral dislocation 
Imaging
  • Radiographs
    • medial subtalar dislocation 
      • talar head will be superior to navicular on lateral image 
    • lateral subtalar dislocation
      • talar head will be colinear or inferior to navicular on lateral image 
  • CT scan
    • perform following reduction
    • look for associated injuries or subtalar debris 
Treatment
  • Nonoperative
    • closed reduction and short leg non-weight bearing cast for 4-6 weeks
      • indications
        • first line of treatment
        • 60-70% can be reduced by closed methods
      • technique
        • requires adequate sedation
        • typical maneuvers include knee flexion and ankle plantar flexion
        • followed by distraction and hindfoot inversion or eversion depending on direction of dislocation
        • perform a post-reduction CT to look for associated injuries
  • Operative
    • open reduction
      • indications
        • failure of closed reduction Shows incidence, mechanism and treatment of subtalar dislocations
          • up to 32% require open reduction
          • medial dislocation reduction blocked by lateral structures including
            • peroneal tendons
            • extensor digitorum brevis 
            • talonavicular joint capsule
          • lateral dislocation reduction blocked by medial structures including
            • posterior tibialis tendon  
            • flexor hallucis longus
            • flexor digitorum longus
          • place temporary transarticular pins as needed if joint remains unstable
Complications
  • Post-traumatic Arthritis
    • long-term follow up of these injuries show degenerative changes 
      • Subtalar joint most commonly affected with up to 89% of patients demonstrating radiographic arthrosis (63% symptomatic)
 

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Questions (6)
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(OBQ09.123) 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? Review Topic

QID: 2936
FIGURES:
1

Tibiotalar joint

5%

(21/440)

2

Talonavicular joint

13%

(58/440)

3

Calcaneocuboid joint

1%

(5/440)

4

Lisfranc joint

10%

(42/440)

5

Subtalar joint

71%

(312/440)

Select Answer to see Preferred Response

PREFERRED RESPONSE 5

(OBQ08.216) 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? Review Topic

QID: 602
FIGURES:
1

Peroneal tendons

18%

(285/1550)

2

Posterior tibial tendon

63%

(969/1550)

3

Extensor retinaculum

3%

(41/1550)

4

Anterior tibial tendon

3%

(42/1550)

5

Flexor hallucis longus

13%

(208/1550)

Select Answer to see Preferred Response

PREFERRED RESPONSE 2

(OBQ12.150) Which of the following is true when comparing Figure A to Figure B? Review Topic

QID: 4510
FIGURES:
1

Figure B is more likely to have an associated fracture

8%

(429/5338)

2

Figure A is more likely to be blocked from closed reduction by the extensor digitorum brevis

12%

(645/5338)

3

FIgure A is more likely to be open

54%

(2898/5338)

4

FIgure B is more likely to be blocked from closed reduction by the posterior tibial tendon

19%

(1004/5338)

5

Figure A more likely to be stable following closed reduction

6%

(310/5338)

Select Answer to see Preferred Response

PREFERRED RESPONSE 3

(OBQ09.76) 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? Review Topic

QID: 2889
FIGURES:
1

Flexor hallucis longus tendon

12%

(395/3373)

2

Extensor digitorum brevis muscle

62%

(2098/3373)

3

Posterior tibial tendon

20%

(683/3373)

4

Tibialis anterior tendon

5%

(171/3373)

5

Plantar fascia

0%

(12/3373)

Select Answer to see Preferred Response

PREFERRED RESPONSE 2

(OBQ04.153) A 40-year-old male suffers the isolated injury shown in figure A with no associated fractures. What joint is dislocated in this radiograph? Review Topic

QID: 1258
FIGURES:
1

Tibiotalar

1%

(9/754)

2

Talonavicular

95%

(713/754)

3

Calcaneocuboid

4%

(30/754)

4

First metatarsophalangeal

0%

(0/754)

5

First tarsometatarsal

0%

(1/754)

Select Answer to see Preferred Response

PREFERRED RESPONSE 2
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