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Subtalar Dislocation
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Contents
Other Names
- Subtalar dislocation
- Talocalcaneal joint dislocation
- Talonavicular joint dislocation
- Total talar dislocation
- Extrusion of the talus
- Pan-talar dislocation
- Luxatio tali totalis
Background
- This page refers to hindfoot dislocations of the Talocalcaneal Joint and Talonavicular Joint
- Commonly referred to as a 'subtalar dislocation'
- This injury should not be confused with an Ankle Dislocation
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
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
- Talus Fracture
- Distal Fibula Fracture
- Distal Tibia Fracture
- Fifth Metatarsal Fracture
- Calcaneus Fracture
- Navicular Fracture
Pathoanatomy
- Subtalar Joint
- Formed by the talus superiorly, the calcaneus and navicular inferiorly
- Posterior chamber: Talocalcaneal Joint
- Anterior chamber: Talocalcanealnavicular Joint
Risk Factors
- Male gender (need citation)
Differential Diagnosis
- Fractures & Dislocations
- Muscle and Tendon Injuries
- Ligament Injuries
- Bursopathies
- Nerve Injuries
- Arthropathies
- Pediatrics
- Fifth Metatarsal Apophysitis (Iselin's Disease)
- Calcaneal Apophysitis (Sever's Disease)
- Triplane Fracture
- Other
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
Complete talar dislocation[10]
Radiographs
- Standard Radiographs Ankle
- Also consider Standard Radiographs Calcaneus
- Medial dislocation
- Talar head superior to navicular on lateral view
- Lateral dislocation
- Talar head is colinear or inferior to navicular on lateral view
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
- Indications
- Roughly 60-70% of cases
- Immobilize
- With Posterior Short Leg Splint with Stirrup or Short Leg Cast with bilvalve
- Duration is typically 4-6 weeks
- Nonweight bearing (NWB)
- Some authors recommend complete NWB during entire period of immobilization[11]
- Physical Therapy
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
- 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
- Internal
- External
- Sports Medicine Review Ankle Pain: https://www.sportsmedreview.com/by-joint/ankle/
References
- ↑ Judey P (1811) Observation dune luxation metatarsienne. Bull Fac Med Paris 11:81–86
- ↑ Broca P (1853) Memories sur les luxations sous-astragaliennes. Mem Soc Chir 3:566–656
- ↑ 3.0 3.1 Malgaigne JF, Buerger CG (1856) Die Knochenbrüche und Verrekungen. Rieger, Stuttgart, p 820
- ↑ DeLee JC, Curtis R et al (1982) Subtalar dislocation of the foot. J Bone Joint Surg Am 64(3):433–437
- ↑ 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
- ↑ Prada-Cañizares, Alfonso, et al. "Subtalar dislocation: management and prognosis for an uncommon orthopaedic condition." International orthopaedics 40.5 (2016): 999-1007.
- ↑ Horning J, DiPreta J (2009) Subtalar dislocation. Orthopedics 32(12):904–908Return to ref 8 in article
- ↑ 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
- ↑ Fortin PT, Kou JX (2009) Commonly missed peritalar injuries. J Am Acad Orthop Surg 17(12):775–786
- ↑ Case courtesy of Dr Matt Skalski. https://radiopaedia.org/cases/25925
- ↑ 11.0 11.1 Merchan EC (1992) Subtalar dislocations: long-term follow-up of 39 cases. Injury 23(2):97–100
- ↑ Simon LC, Shulz AP (2008) “Basketball Foot”—long time prognosis after peritalar dislocation. Sportverletz Sportschaden 22:31–37
- ↑ 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
- ↑ Saltzman C, Marsh JL (1997) Hindfoot dislocations: when are they not benign? J Am Acad Orthop Surg 5(4):192–198
- ↑ 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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