Fractures of the Lateral Process of the Talus Retrospective Study of 44 Cases 2008 Revue de Chirurgie Orthop Dique Et R Paratrice de l Appareil Moteur

7/24/2019 Fractures of the Lateral Process of the Talus Retrospective Study of 44 Cases 2008 Revue de Chirurgie Orthop Dique Et R Paratrice de l Appareil Moteur

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Revue de chirurgie orthopdique et rparatrice de lappareil moteur (2008)94, e1e7

D i s p o n i b le e n l i g n e s u r w w w . s c i en c e d i r e c t .c o m

ORIGINAL ARTICLE

Fractures of the lateral process of the talus.Retrospective study of 44 cases

Fractures et squelles de fractures de lapophyselatrale du talus. tude rtrospective propos

de 44 casE. Sariali , J.-F. Lelivre, Y. Catonn

Service de chirurgie orthopdique et traumatologique, hpital la Piti-Salptrire, 4783, boulevard de lHpital,

75651 Paris cedex 13, France

Accepted 25 April 2008

KEYWORDSLateral process;Talus;Fracture

SummaryPurpose of the study. Fractures of the lateral process of the talus often go undiagnosed. The

cohorts reported in the literature are small. The aim of the study was to analyze these fractures

with a large group of patients.

Materials and methods. Forty-four fractures in 43 patients were reviewed with a mean follow-

up of 17 months. The diagnosis had been made immediately in 14 cases and secondarily in

30 cases with a delay of 46 months. Patients were evaluated with Kitaokas score and X-rays

using Hawkins classification. Fractures occurred during sports in 19 cases. The most frequent

mechanism was association of dorsal flexion and pronation. There were associated lesions in

44% of cases.

Results. In the delayed diagnosis group, we found 14 cases of associated pseudarthrosis and

subtalar osteoarthritis, two cases of isolated pseudarthrosis and two cases of isolated subtalar

osteoarthritis. After treatment, the result at the last follow-up was excellent in 15 of these

cases (50%), good in seven cases (23%), fair in seven cases (23%) and poor in one case (4%). In the

immediate diagnosis group, five of 14 patients had at least one complication: 29% pseudarthro-sis and 29% subtalar osteoarthritis. After treatment, the result at the last follow-up in this

group was excellent in eight cases (58%), good in four cases (28%) and fair in two cases (14%).

Immediate diagnosis was correlated with better results at the last follow-up. In the immediate

diagnosis group, among patients who had orthopedic treatment, the rate of secondary surgery

was 42%.

DOI of original article:10.1016/j.rco.2007.04.005. Corresponding author.

E-mail address:[email protected](E. Sariali).

0035-1040/$ see front matter 2008 Elsevier Masson SAS. All rights reserved.doi:10.1016/j.rco.2008.04.009
http://localhost/var/www/apps/conversion/tmp/scratch_3/dx.doi.org/10.1016/j.rco.2007.04.005mailto:[email protected]://localhost/var/www/apps/conversion/tmp/scratch_3/dx.doi.org/10.1016/j.rco.2008.04.009http://localhost/var/www/apps/conversion/tmp/scratch_3/dx.doi.org/10.1016/j.rco.2008.04.009mailto:[email protected]://localhost/var/www/apps/conversion/tmp/scratch_3/dx.doi.org/10.1016/j.rco.2007.04.005


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e2 E. Sariali et al.

Conclusion. Fracture of the lateral process of the talus is quite frequent and occurs among

young people. Spontaneous progression is severe, with two major complications: pseudarthrosis

and subtalar osteoarthritis. Treatment is always required in case of displaced fracture.

2008 Elsevier Masson SAS. All rights reserved.

MOTS CLSApophyse latrale ;

Talus ;Fracture

Rsum Quarante-quatre fractures de lapophyse latrale du talus chez 43 patients ont trevues avec un recul mdian de 17 mois. Le diagnostic avait t pos en post-traumatique

immdiat dans 14 cas et secondairement dans 30 cas avec un dlai diagnostique moyen de

46 mois. Lvaluation a t clinique avec le score objectif de Kitaoka et radiologique avec

la classification de Hawkins. Le mcanisme le plus frquent tait une hyperflexion dorsale

associe une pronation. Il existait des lsions associes dans 44 % des cas. Dans le groupe

de diagnostic tardif 14 patients prsentaient une pseudarthrose associe une arthrose sous-

talienne postrieure, deux patients une pseudarthrose isole et deux une arthrose sous-talienne

isole. Aprs traitement, le rsultat tait trs bon dans 15 cas (50 %), bon dans sept (23 %),

moyen dans sept (23%) et mauvais dans un cas (4 %). Dans le groupe de diagnostic prcoce,

cinq sur 14 patients ont prsent au moins une complication. Aprs traitement, le rsultat

tait trs bon dans huit cas (58%), bon dans quatre (28 %) et moyen dans deux (14 %). Parmi

les patients du groupe prcoce traits orthopdiquement, le taux de chirurgie secondaire tait

42 %. Cette fracture est relativement frquente et touche le sujet jeune. Son volution naturelle

est svre avec deux complications majeures, la pseudarthrose et larthrose sous-talienne. Le

dlai diagnostic semble tre un lment pronostic. Le diagnostic est fait sur le scanner avec

reconstruction frontale. Le traitement doit tre chirurgical en cas de dplacement avec exrse

ou synthse selon la taille du fragment. En cas de dgradation secondaire, on peut proposerune arthrodse sous-talienne.

2008 Elsevier Masson SAS. All rights reserved.

Introduction

Fractures of the lateral process of the talus are reputedto be rare, since according to Butel and Witvet [1] theyaccount for less than 2% of talar fractures. Most publishedreports describe only one to three cases. The largest serieswere reported by Hawkins[2] and Murkherjee et al.[3](13cases each). With the low number of cases in these studies,the literature provides no precise data on the prevalence,mechanism and complications of this lesion.

The objective of our retrospective study of 44 cases wasto analyze:

the characteristics of this fracture, including its mecha-nism, natural course and complications;

the surgical indications.

Materials and methods

A retrospective study of 44 consecutive fractures of the lat-eral process of the talus in 43 patients was conducted inthe Piti-Salptrire and Fort-de-France hospital orthopedicsurgery departments. The patients were treated betweenJanuary 1992 and November 2000, immediately after injuryin 14 cases and secondarily in 30 cases.

Etiology and mechanism

In 19 cases, the fracture occurred while doing sports: snow-boarding (five cases), football (four cases) and one caseof a stress fracture in a long-distance runner whose X-rayshowed a long, slender process. In 14 cases, the fracture was

secondary to a motor vehicle accident, with five patientsmotorcycle riders and nine passenger car drivers. Of thesedrivers, seven had the foot stuck in dorsal flexion on thebrake pedal during the impact. In 11 cases, the fractureoccurred during a fall, with four patients falling from a sub-stantial height.

The mechanism at work was clearly established in 24 outof 44 cases. A dorsal flexion was found in 20 cases (83%),

isolated in seven cases (29%) and was associated with prona-tion in 10 cases (42%) and supination in three cases (13%).Isolated supination was found in four cases (17%). The mostfrequent mechanism was therefore dorsal flexion associatedwith pronation. Among the patients in whom the mecha-nism was not formally identified, two patients presenteda medial collateral ligament lesion, suggesting a pronationmechanism.

Patients and treatments

The patient series comprised 11 women and 32 men aged1369 years (mean, 33 years16) with a clear predom-

inance of the 25- to 39-year-old age group. There wasone case of bilateral fracture. Twenty-five took part ina sport, five at a competitive level, 14 regularly and sixoccasionally.

Immediate diagnosis group

This group of patients was made up of 14 men aged 2050years (mean, 32 years8). According to the Hawkins clas-sification, the fracture was type I in 10 cases, type II intwo cases and type III in two cases. There were associatedlesions in six cases (44%): five fractures (two at the neck of


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Fractures of the lateral process of the talus. Retrospective study of 44 cases e3

Figure1 Example of immediate surgical treatment: osteosyn-thesis with screw fixation.

the talus, one at the sustentaculum tali, one fracture of themedial tubercle, one fracture of the lateral malleolar point)and a rupture of the talocalcaneal ligament associated withsubtalar dislocation.

Twelve patients received orthopedic treatment (immo-bilization with a foot cast and no weightbearing for 45days) and two surgically (osteosynthesis by direct screw fixa-tion, then immobilization with no weightbearing for 45 days)(Fig. 1). Patients were reviewed with a follow-up of six to49 months (median, 12 months).

Delayed diagnosis group

This group included 30 patients made up of 11 women and19 men from 13 to 69 years of age (mean, 35 years 13) withthe 25- to 39-year-old age group predominating. The meantime to diagnosis was 46 months. The patients consultedfor persistent pain after injury to the ankle that had beendiagnosed as sprain. The functional complaint was painful

restriction of the walking perimeter in 75% of cases anddiscomfort during sports activity in 25% of cases. Accord-ing to the Hawkins classification, the fracture was type I in15 cases, type II in three cases and type III in 12 cases. Therewere associated lesions in 13 cases (44%): five fractures (onesustentaculum tali, two lateral thalamic fractures, one talardome fracture, one lateral malleolus fracture), four talo-calcaneal ligament tears, one mediotarsal dislocation andthree lateral fibular dislocations. In the immediate post-traumatic period, even though the diagnosis had not beenmade, 10 patients were treated with orthopedics for seriousankle sprain, with immobilization in a foot cast for four tosix weeks. Twenty patients had no specific treatment.

At diagnosis, 14 patients presented pseudarthrosis asso-ciated with posterior subtalar osteoarthritis, two patientsshowed isolated pseudarthrosis, two isolated subtalarosteoarthritis, seven malunion and four reflex sympatheticdystrophy. We had a total of 16 cases of pseudarthrosis, 16cases of subtalar osteoarthritis, seven cases of malunion andfour cases of reflex sympathetic dystrophy. The secondarytreatment was medical in eight cases (subtalar infiltration),orthopedic in one case and surgical in 21 cases, with excisionof the fragment in 14 cases (Fig. 2),subtalar arthrodesis infive cases (Fig. 3)and osteotomy of the calcaneus by directscrew fixation in two patients (Fig. 4). The patients wereseen again for follow-up after six to 60 months (median,17.2 months).

Figure 2 Example of secondary treatment: excision of the fragment.


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Figure 3 Example of secondary treatment: subtalar osteoarthritis.

Analysis

Patients were evaluated clinically and radiologically. Forthe clinical and functional evaluation, we used the Kitaokaand Patzer score [4], which analyzed pain, functionalconstraints, walking perimeter, as well as tibiotarsal andsubtalar mobility. The initial fracture was analyzed on plainfrontal, lateral and three-quarter view ankle X-rays, as wellas on a CT scan of the ankle, which allowed us to analyze theassociated ligament lesions, particularly the talocalcanealligament. At the last follow-up, the patients were evaluated

on plain X-rays with load. The Hawkins[2] fracture classifi-

Figure 4 Example of secondary treatment with osteotomy ofthe malunion and osteosynthesis.

cation was used. The result was considered excellent if theKitaoka score was over 95, good if it was between 80 and 95,fair if it was between 50 and 80, and poor if it was below50. We analyzed the complications and the results in twogroups: immediate and late diagnosis. Finally, we attemptedto identify the prognostic factors, particularly the influenceof diagnosis delay.

The statistical analysis was done with JMP software.We used the Student t-test for the quantitative variablesand Pearsons Chi-square test for the qualitative variables.Statistical significance wasp < 0.05.

Results

Results of the immediate diagnosis group (14 cases)

Five (36%) patients presented at least one complication:three patients presented pseudarthrosis associated withsubtalar osteoarthritis, one patient had isolated pseu-darthrosis and one patient isolated subtalar osteoarthritis.We had a total of four (29%) cases of pseudarthrosis andfour cases (29%) of subtalar osteoarthritis. All patients whopresented a complication had initially been treated orthope-

dically. As for the patients presenting with pseudarthrosis,three corresponded to stage I with displacement (35 mm)and one to stage II, the latter having retained his immobi-lization device only two weeks. For the cases of subtalarosteoarthritis, we had two stage I patients with displace-ment (35mm) and two stage II patients who did not achieveosteosynthesis.

The secondary treatment was surgical in all cases withosteosynthesis, two fragment excisions and two subtalararthrodeses. At the last follow-up, the mean Kitaoka scorewas 86.715 (range, 52100). We had eight (58%) excellentresults, four (28%) good results and two (14%) fair results(mean score, 52) (Fig. 5).


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For one of these last two patients, initially treated withorthopedics and who developed subtalar osteoarthritis, themean results corresponded to stage I with displacement(4 mm); review surgery consisted of simple excision of thefragment. The second patient was classified as stage II andhad developed chronic instability in the ankle for whichligamentoplasty of the lateral collateral ligament was per-formed at the same time as the fragment was excised.

Results of the delayed diagnosis group (30 cases)

One complication after secondary treatment was noted infive patients (16%): a postoperative Staphylococcus aureusinfection that was reoperated with a poor result, two casesof reflex sympathetic dystrophy treated medically with onegood and one fair result, two cases of subtalar osteoarthritisdeterioration after fragment excision, treated with subtalararthrodesis with one good result and one fair result becauseof associated tibiotarsal osteoarthritis secondary to an asso-ciated fracture of the talar dome.

At the last follow-up, the mean Kitaoka score was

83.518 (range, 38100). We had 15 (50%) excellentresults, seven (23%) good results, seven (23%) fair results(4%) and one poor result (Fig. 5).

Overall results

In the overall series, we had 23 (52%) excellent results, 11(23%) good results, nine (21%) fair results and one (2%) poorresult.

Prognostic factors

After secondary treatment, there was no significant dif-

ference between the two groups in the Kitaoka score.However, we noted a strong trend with the mean Kitaokascore increased by 3.3 points in the immediate diagnosisgroup (86.8 versus 83.5; p = 0.09). The rate of good andexcellent results was high in the immediate diagnosis group(86% versus 73%; p = 0.05). In the delayed diagnosis group,the rate of subtalar osteoarthritis was significantly higherthan in the other group (53% versus 29%; p = 0.02); how-ever, there was no significant difference in the number ofsubtalar arthrodesis cases (p = 0.17). In the immediate diag-

Figure 5 Results at last follow-up in the delayed diagnosisgroup and the immediate diagnosis group. The figure shows the

rate (%) of the result for each group.

Figure 6 Number of patients by type of treatment and by

group related to time of diagnosis. The first line indicates themean Kitaoka score by group at the last follow-up.

nosis group, of the 12 patients treated orthopedically, fiveunderwent secondary surgery (42%) (Fig. 6). The patientswho were immediately treated surgically had an excellentresult, with a mean score of 92.5. There was no correlationbetween the radiological stage and the final result (p = 0.09)in both groups.

Discussion

Fractures of the lateral process of the talus are reputed tobe rare (2% according to Butel and Witwoet[1]).Their fre-quency is undoubtedly underestimated because they oftengo unnoticed, as Judd and Kim[5]have reported. Accordingto Baumhauer and Alvarez[6],they may reach 24% of talusfractures, 30% according to Hawkins[2]. In our series, thisfracture was initially unrecognized in 68% of cases, with adiagnosis of sprained ankle made at the time of injury. AsSharma[7] has reported, patients consult later for chroniclateral premalleolar pain in what certain authors[8,9]callsinus tarsi syndrome. Most studies report only one to threecases. The largest series were reported by Hawkins[2] (13cases) and Murkherjee et al. [3](13 cases).

This fracture is currently presented as a snowboarderfracture[1015].Falling from a height is a frequent cause,as indicated by Hawkins[2](five out of 13) and Murkherjeeet al. [3] (nine out of 13). Our series only contained fourinstances of falling. We found mainly accidents occurringduring sports activity (19/44) with sports that risked forceddorsal flexion of the foot such as snowboarding and waterskiing. We had one case of a stress fracture in a marathonrunner, whose apophysis was long and slender. A few iden-tical cases have been reported in the literature [1618].Inour series, traffic accidents were frequent[14],often withabrupt dorsal flexion caused by the foot getting stuck on thebrake pedal.


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Figure 7 Nutcracker effect. The lateral process is pinchedbetween the external malleolus and the external surface of the

thalamus in dorsiflexion, which probably explains the frequency

of this mechanism.

As for the mechanism involved, the data reported inthe literature are not always in agreement. For Hawkins[2] and Fjeldborg [19], the fracture is secondary to dor-sal flexion associated with inversion. The cadaver studyconducted by Boon et al. [10] showed that the fracturecould be reproduced in axial compression with externalrotation, whereas Funk et al. [11] reproduced the frac-ture in dorsal flexion and eversion. In our series, the mostfrequent mechanism we found was dorsal flexion asso-ciated with pronation. The fracture may very well becaused by a nutcracker effect, with the lateral processpinched between the lateral malleolus and the lateral tha-

lamus surface (Fig. 7). The existence of lateral malleolusor lateral thalamus surface fractures and medial collat-eral ligament lesions argues in favor of this mechanism.The inversion mechanism remains difficult to explain. Theapophysis may be pulled out, sometimes with insertionof an accessory band coming from the fibulocalcaneal lig-ament, such as that reported by Trouilloud et al. [20].In our series, this mechanism was found in only fourcases.

The fracture is often not recognized at first because thefracture line can be difficult to identify on the plain X-ray.The lateral process is better visualized on three-quarterviews. CT is the reference exam, which makes it possibleto analyze the fracture and evaluate the possible associated

bone and ligament lesions, particularly the talocalcaneal lig-ament. Sonographic techniques [21] have been proposed,but they are operator-dependent and less sensitive. MRI[22]provides a better analysis of the associated ligamentlesions but remains less useful in the analysis of the fracture.CT with frontal reconstructions through the lateral processremains the reference examination.

We showed the natural course and the severity of thisfracture with the delayed diagnosis group. Three types offrequent complications were seen: pseudarthrosis, subta-lar osteoarthritis and malunion, which was responsible forpain in the lateral malleolus. These complications can beassociated.

Even when the lesions were treated immediately, thecomplication rate remained high, with 29% of subtalarosteoarthritis. This pleads in favor of the arthrogenic natureof this fracture. Excision of the fragments improves thesymptoms but does not seem to prevent progression towardsubtalar osteoarthritis, particularly since we have notedthat two out of four cases worsened after the fragmentwas excised. The progression toward osteoarthritis can also

be explained by the frequent associated lesions (44% inour series), particularly osteochondral lesions and ligamentlesions. We had five cases of talocalcaneal ligament tear,all progressing toward subtalar osteoarthritis, which can beexplained by secondary subtalar instability.

A delay in diagnosis seems to be a prognostic factorsince the rate of good and excellent results was higherin the immediate diagnosis group and the rate of subtalarosteoarthritis was higher in the delayed diagnosis group.However, there was no significant difference between thetwo groups for the rate of arthrodesis.

In the immediate diagnosis group, treatment was initiallysurgical in only two cases and was secondary in five (42%).This shows that there are probably broader indications for

initial surgery. The poor results corresponded to displacedfractures (> 3 mm) that cannot be treated surgically, giventhe size of the fragment or to subtalar osteoarthritis. Dis-placed fractures should be treated surgically with excisionof the fragment or with osteosynthesis if the fragmentsize allows it. Secondary progression toward symptomaticsecondary osteoarthritis could therefore be treated withsecondary subtalar arthrodesis, for which the results seemgood.

Conclusion

Lateral process fractures of the talus are relatively frequentand often go unrecognized. They affect young subjects.The natural course is severe, with two major complica-tions: pseudarthrosis and subtalar osteoarthritis. Diagnosticdelay has a prognostic value. The most frequent mechanismfound was dorsal flexion associated with pronation. Thereare frequently associated lesions. This should be systemati-cally suggested when premalleolar pain persists after ankleinjury. A CT scan of the ankle with frontal reconstructionthrough the apophysis should be taken because diagnosis canbe difficult, especially in stage III cases.

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[6] Baumhauer JF, Alvarez RG. Controversies in treating talar frac-tures. Orthop Clin North Am 1995;26:33551.


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[9] Pisani G, Pisani PC, Parino E. Sinus tarsi syndrome and subtalarjoint instability. Clin Podiatr Med Surg 2005;22:6377.

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[15] Chan GM, Yoshida D. Fracture of the lateral process ofthe talus associated with snowboarding. Am J Emerg Med2003;41:8548.

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Fractures of the Lateral Process of the Talus Retrospective Study of 44 Cases 2008 Revue de Chirurgie Orthop Dique Et R Paratrice de l Appareil Moteur