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Subtalar Dislocation

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Other Names

  • Subtalar dislocation
  • Talocalcaneal joint dislocation
  • Talonavicular joint dislocation
  • Total talar dislocation
  • Extrusion of the talus
  • Pan-talar dislocation
  • Luxatio tali totalis

Background

History

  • First described by Judey in 1811[1]
  • Classification first proposed by Broca (1853)[2] which was modified by Malgaigne and Buerger (1856)[3]

Epidemiology

  • Subtalar dislocations make up 1-2% of all dislocations (need citation)
  • Represent 1% of all traumatic injuries to the foot[4]
  • Associated with
    • 46-83% of case are open, depending on reference material[5]
    • Up to 44% have fractures (need citation)

Pathophysiology

Medial subtalar dislocation[6]
  • Definition of subtalar dislocation
    • Disruption of articulation of the Talus to the Calcaneus
    • Simultaneous dislocation of the talocalcaneal and talo-navicular joints
    • Absence of tibio-talar or talar neck associated fractures

Etiology

  • High energy
    • Most common
    • Examples include Motor vehicle accident, fall from height
  • Low energy
    • Less common
    • Can occur during sports or twisting injuries of the foot

Direction of dislocation

  • Medial (80–85%)[7]
  • Lateral (15–20%)[8]
    • More likely to have soft tissue, osseous injuries
    • More likely to require open reduction
    • Neurovascular injuries have been identified in up to 70 % of cases[9]
  • Posterior (2.5%)
  • Anterior (1%)
  • Total talar dislocation
    • tri-articular dislocation of talus at the tibiotalar, talonavicular and subtalar joints

Associated Conditions

Pathoanatomy


Risk Factors

  • Male gender (need citation)

Differential Diagnosis


Clinical Features

  • History
    • Patient should be able to describe their injury pattern
    • Will endorse ankle/ foot pain, swelling, deformity
    • Inability to ambulate
  • Physical Exam
    • Gross deformity of ankle
    • Soft tissue injury may or may not be present (i.e. open/closed)
    • Locked in supination with medial dislocation, pronation with lateral dislocation
  • Special Tests

Evaluation

Radiographs

CT

  • Should be obtained after reduction
  • Helpful to
    • confirm adequate reduction
    • Exclude associated lesions

MRI

  • Role in subtalar dislocation is not well described
  • May be helpful to evaluate the soft tissues

Classification

  • Description
    • Based on position of foot relative to talus at the time of injury[3]
  • Medial dislocation
    • Foot: plantarflexed and inverted followed by an external rotation to the talus
    • Foot is locked in supination
  • Lateral dislocation
    • Foot: foot is everted on plantarflexed foot at time of injury
    • Foot is locked in pronation
    • More likely to be open
  • Anterior and Posterior dislocation
    • Foot: pulls the foot in forced plantar flexion or translate it in anterior direction
  • Total dislocation
    • Complete dislocation of talus from ankle, subtalar, talonavicular joints
    • Usually open

Management

Acute

  • Follow ATLS algorithm as needed depending on mechanism of injury
  • Closed Reduction
    • Should be performed emergently, typically in ED (or OR)
    • Under procedural sedation (or general anesthesia)
    • Keep knee flexed to relax calf muscles
    • Immobilization with Posterior Short Leg Splint with Stirrup or Short Leg Cast with bilvalve
  • Approximately 32% require open reduction (need citation)

Nonoperative

Operative

  • Indications
    • Instability
    • Associated injuries
    • Irreducible with closed reduction
    • Open dislocations
    • Failure of closed reduction
  • Technique
    • Stabilization with K wires
    • External fixation

Rehab and Return to Play

Rehabilitation

  • Needs to be updated

Return to Play/ Work

  • Needs to be updated

Complications and Prognosis

Prognosis

  • Functional outcomes
    • Some authors have reported high AOFAS scores in isolated dislocations
    • When associated injuries are included, about 1/3 of patients report good results with pain, mobility
    • Another study reported stiffness (100%), degenerative changes (100%) and pain with ambulation (50%)[5]
    • Worse outcomes associated with high energy, lateral, open, concomitant fracture
  • Increased energy during trauma correlates with
    • Open injuries
    • Need for open reduction
    • Worse functional outcomes
  • Presence of associated injuries
    • Increased likelihood of having a poor outcome[11]
    • Talus neck fracture associated with AVN, stiffness, osteoarthritis, osteochondral lesion[12]
  • Type of dislocation
    • Some studies show difference in outcomes with type of dislocation
    • De Palma showed worse functional outcomes with medial dislocations[13]
    • Lateral dislocations associated with higher frequency of soft tissue injury, fractures, AVN, need for ORIF

Acute Complications

  • Open injury
    • Reported to occur in 46-83% of total cases[5]
  • Neurovascular injury
  • Infection

Chronic Complications

  • Post-traumatic Osteoarthritis
    • Most common cause of pain, disability in the long term[14]
    • Incidence ranges from 16% to 70%
  • Chronic subtalar instability
    • Defined as subjective feeling of ankle instability, easy "rolling over" or need to look at ground when walking
    • Reported in 0-55% of cases
    • Risk increases with younger age, shorter time of immobilization
  • Complex Regional Pain Syndrome
  • Avascular Necrosis of talus
    • Reported in high energy injuries with associated fracture
    • In one study, 1/3 of patients with open subtalar dislocations developed AVN[5]
  • Subtalar joint stiffness
    • Reported in up to 70% of cases[15]
    • Recommended to reduce period of immobilization to reduce risk

See Also


References

  1. Judey P (1811) Observation dune luxation metatarsienne. Bull Fac Med Paris 11:81–86
  2. Broca P (1853) Memories sur les luxations sous-astragaliennes. Mem Soc Chir 3:566–656
  3. 3.0 3.1 Malgaigne JF, Buerger CG (1856) Die Knochenbrüche und Verrekungen. Rieger, Stuttgart, p 820
  4. DeLee JC, Curtis R et al (1982) Subtalar dislocation of the foot. J Bone Joint Surg Am 64(3):433–437
  5. 5.0 5.1 5.2 5.3 Goldner JL, Poletti SC, Gates HS 3rd, Richardson WJ (1995) Severe open subtalar dislocations. Long-term results. J Bone Joint Surg Am 77(7):1075–1079
  6. Prada-Cañizares, Alfonso, et al. "Subtalar dislocation: management and prognosis for an uncommon orthopaedic condition." International orthopaedics 40.5 (2016): 999-1007.
  7. Horning J, DiPreta J (2009) Subtalar dislocation. Orthopedics 32(12):904–908Return to ref 8 in article
  8. Jungbluth P, Wild M, Hakimi M, Gehrmann S, Djurisic M, Windolf J, Muhr G, Kälicke T (2010) Isolated subtalar dislocation. J Bone Joint Surg Am 92(4):890–894Return
  9. Fortin PT, Kou JX (2009) Commonly missed peritalar injuries. J Am Acad Orthop Surg 17(12):775–786
  10. Case courtesy of Dr Matt Skalski. https://radiopaedia.org/cases/25925
  11. 11.0 11.1 Merchan EC (1992) Subtalar dislocations: long-term follow-up of 39 cases. Injury 23(2):97–100
  12. Simon LC, Shulz AP (2008) “Basketball Foot”—long time prognosis after peritalar dislocation. Sportverletz Sportschaden 22:31–37
  13. de Palma L, Santucci A, Marinelli M, Borgogno E, Catalani A (2008) Clinical outcome of closed isolated subtalar dislocations. Arch Orthop Trauma Surg 128(6):593–598
  14. Saltzman C, Marsh JL (1997) Hindfoot dislocations: when are they not benign? J Am Acad Orthop Surg 5(4):192–198
  15. Perugia D, Basile A, Massoni C, Gumina S, Rossi F, Ferretti A (2002) Conservative treatment of subtalar dislocations. Int Orthop 26(1):56–60
Created by:
John Kiel on 6 July 2021 17:37:19
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Last edited:
3 October 2022 23:54:10
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