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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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