|Year : 2019 | Volume
| Issue : 4 | Page : 61-64
Isolated medial subtalar dislocation: the importance of early mobilization
Supreeth Nekkanti, Arunodhaya Siddartha, P Tushar
Department of Orthopaedics, Jagadguru Sri Shivarathreeshwara Hospital, Mysore, India
|Date of Submission||20-Mar-2019|
|Date of Decision||26-Mar-2019|
|Date of Acceptance||31-Jul-2019|
|Date of Web Publication||18-Dec-2019|
Department of Orthopaedics, Jagadguru Sri Shivarathreeshwara Hospital, Mysore
Source of Support: None, Conflict of Interest: None
Background and objective: Isolated subtalar dislocations are rare injuries. Current studies have reported that it requires 5 or 6 weeks immobilization after the injury. The purpose of this study was to understand the effect of 4-week immobilization on the recovery of foot function after isolated medial subtalar dislocation.
Subject and methods: We reported a rare case of an isolated medial subtalar dislocation in a male who was immobilized for only 4 weeks after closed reduction under anesthesia. The patient underwent early mobilization of the feet and ankles. This report has been submitted after due approval from the Institutional Review Board of Jagadguru Sri Shivarathreeshwara Hospital, India.
Results: The patient was successfully managed by closed reduction under anesthesia. The foot function of the patient recovered well at 6 months of follow-up. The results of 1-year follow-up showed that the foot function was basically normal.
Conclusion: Early closed reduction and early mobilization of the foot and ankle ensured the good functional outcome.
Keywords: subtalar dislocations; anesthesia; closed reduction; early mobilization; immobilization
|How to cite this article:|
Nekkanti S, Siddartha A, Tushar P. Isolated medial subtalar dislocation: the importance of early mobilization. Clin Trials Orthop Disord 2019;4:61-4
|How to cite this URL:|
Nekkanti S, Siddartha A, Tushar P. Isolated medial subtalar dislocation: the importance of early mobilization. Clin Trials Orthop Disord [serial online] 2019 [cited 2020 Jan 22];4:61-4. Available from: http://www.clinicalto.com/text.asp?2019/4/4/61/272834
| Introduction|| |
Acute subtalar dislocations constitute less than 1–2% of all large joint dislocations making it an uncommon injury.,, Subtalar dislocations form 15% of all talar injuries. Men are 3–10 times more vulnerable to these injuries. Three forms of subtalar dislocations namely medial, lateral and posterior dislocation have been identified.,,, The direction of the rest of the foot with respect to the talus was determinant in identifying the type of subtalar dislocations as medial, lateral or posterior dislocation. Another variant called the anterior subtalar dislocation has been added later., Medial subtalar dislocation is more common in occurrence with an incidence of 79.5% followed by lateral subtalar dislocation. These injuries are usually associated with talar fractures, malleolar fractures or the fifth metatarsal fracture. Isolated subtalar dislocations in the absence of associated fractures are extremely rare and form less than one-third of the cases of subtalar dislocations. In this study, we aimed to understand the effect of 4-week immobilization on the recovery of foot function after isolated medial subtalar dislocation. We reported such a case of isolated medial subtalar dislocation successfully managed by closed reduction under anesthesia in a 21-year-old male patient followed by early mobilization of the ankle.
| Subject and Methods|| |
This report has been submitted after due approval from the Institutional Review Board of Jagadguru Sri Shivarathreeshwara Hospital, India. This study was conducted in accordance with the Declaration of Helsinki. The patient signed the written informed consent.
We reported a 21-year-old boy with injury to left foot while trying to get off a moving bus. He presented to us in the emergency department within 3 hours of injury with complaints of pain and deformity of the foot and inability to bear weight. On examination, there was diffuse swelling over the ankle and foot. The head of the talus was palpated dorsolateral in the foot; dorsalis pedis and posterior tibial artery pulsations were felt [Figure 1]. The limb was immobilized by a temporary splint to alleviate the pain, and plain radiographs were taken. Radiographs revealed medial subtalar dislocation [Figure 2]. Computed tomography (CT) scans revealed no associated fractures [Figure 3]. The patient was subjected to the prompt closed reduction under spinal anesthesia. A lateral pressure was applied to head of talus with the knee joint in flexion, ankle plantar flexion and midfoot in eversion. The talus fell into place and the reduction was confirmed by radiography [Figure 4]. Dorsalis pedis & posterior tibial artery pulsations were palpated and strong after closed reduction. The limb was immobilized using a short leg below knee slab.
|Figure 1: Clinical photograph showing the clubfoot deformity of the left foot.|
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|Figure 2: Pre-reduction radiograph of the left foot showing isolated medial subtalar dislocation.|
Note: Medial subtalar dislocation is found. AP: Anteroposterior; LAT: lateral; OBL: oblique radiological views.
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|Figure 3: Computed tomography scan image of the left foot confirming isolated medial subtalar dislocation.|
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|Figure 4: Immediate post-reduction radiograph of the left foot.|
Note: The subtalar joint is articulated well (arrow).
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| Results|| |
Our patient had no associated fractures, prompt closed reduction was executed and immobilization did not exceed 4 weeks. We observed an excellent functional outcome.
| Discussion|| |
Hoexum and Heetveld reviewed 359 cases of subtalar dislocations and reported that 50–80% of these injuries were due to high-energy trauma. Medial subtalar dislocation occurs due to forceful inversion of the forefoot with the ankle in plantar flexion. The talus pivots on the sustentaculum tali. During the impact, the severe varus force ruptures the talonavicular and talocalcaneal ligaments, leading to subtalar dislocation. A similar injury mechanism could be explained due to a strong inversion force on a plantar-flexed ankle in our patient as he was trying to get off a moving bus. The appearance of the foot following such an injury resembles that of a clubfoot and hence the name “acquired clubfoot” is given.
Early and prompt closed reduction under anesthesia is the preferred first line of management. This minimizes soft tissue damage and reduces the incidence of avascular necrosis of talus. Approximately 10% of the cases of medial subtalar dislocations fail to reduce by closed methods. The reasons could probably be bony blocks by fracture fragments of the talar head which disallow the closed reduction maneuver or interspostion of extensor retinaculum., Surgery is indicated in these cases. Post-reduction CT scans are strongly recommended to avoid missing associated fractures which may not be evident in plain radiographs. In our patient, initial radiographs and CT scans ruled out any associated fractures and a successful closed reduction maneuver was performed under spinal anesthesia.
Medial subtalar dislocation has been reported to have better outcomes than lateral subtalar dislocation. This has been attributed to the fact that a larger amount of force is required to cause a lateral subtalar dislocation and it is usually associated with fractures of the talus, metatarsals or bimalleolar fractures., Jungbluth et al. reported good results in 21 out of 23 patients with isolated subtalar dislocations and satisfactory results in two patients after conservative treatment. There was no difference observed between the outcomes of closed reduction of medial and lateral subtalar dislocations. Heppenstall et al. reported excellent results in 14 out of 19 cases of isolated subtalar dislocations managed by closed reduction. Poor results were observed in 10–32% of cases of lateral subtalar dislocation managed by closed reduction.
After closed reduction, the foot is immobilized in a cast. The optimal duration of immobilization is controversial. DeLee and Curtis reported poor outcomes in patients who were immobilized for more than 3 weeks. de Palma et al. reported that isolated subtalar dislocation patients needed to be immobilized for 5 weeks. A group of surgeons have reported that an immobilization period of less than 4 weeks is insufficient for the soft tissues to heal around the foot which may lead to poor outcomes.,, Our patient was immobilized for only 4 weeks instead of 5 or 6 weeks as described in the literature. Our patient had a good function of his foot at the end of 6 months. Excellent outcomes were observed at the end of 1-year follow-up.
The prognosis of these injuries depends on the nature of injury. Medial subtalar dislocation had been reported to have better outcomes than lateral subtalar dislocation. Associated osseous or cartilaginous injuries have shown poorer outcomes compared to isolated subtalar dislocations. Duration of immobilization also plays a vital role in the outcome of the patient. Lasanianos et al. described that an excellent outcome could be achieved if three criteria are met during the treatment: (1) Low-energy forces are applied on soft tissue envelope during injury; (2) prompt and early closed reduction is performed under anesthesia; (3) immobilisation for a short period of time. Our patient had no associated fractures, prompt closed reduction was executed and immobilization did not exceed 4 weeks. We observed an excellent functional outcome.
Long-term complications of these injuries include posttraumatic arthritis, osteonecrosis of talus and subtalar stiffness. Heppenstall et al. reported that 80% of subtalar dislocations will demonstrate restricted range of movements of the subtalar and/or the ankle joint eventually. They also reported 50–80% of the patients will demonstrate radiographic changes of subtalar arthritis. The incidence of osteonecrosis of talus was reported to be 10–29%. Jarde el al. reported 3 cases out of 35 to develop osteonecrosis of talus after one year of injury. CT angiography or Doppler studies could be performed to rule out vascular compromise associated with isolated subtalar dislocations if clinical signs like absence or feeble pulse and/or signs of ischemia persist. The exact incidence of vascular injuries associated with subtalar dislocations has not been reported. Our patient had a terminal 10° restriction of movement of the ankle.
Post-traumatic fibrosis of the soft tissues around foot and ankle occurs due to the high velocity of injury and is mainly responsible for ankle stiffness. Degenerative changes are uncommon secondary to ankle stiffness induced by fibrosis. Ankle stiffness could be reduced by reducing the duration of immobilization., Patients with isolated subtalar dislocations are recommended to be immobilized for less than 4 weeks and cases of subtalar dislocations with associated fractures are to be immobilized for less than 6 weeks for good functional outcomes. Our patient did not have any radiographic evidence of subtalar arthritis.
| Conclusion|| |
Isolated subtalar dislocations are rare injuries. Early diagnosis and prompt closed reduction under anesthesia usually yield good outcomes. An optimal period of immobilization goes a long way in providing good to excellent outcomes of these serious injuries.
All authors contributed to study design, data collection, and paper writing, and approved the final paper.
Conflicts of interest
The authors have no conflicts of interest to declare.
Institutional review board statement
This report has been submitted after due approval from the Institutional Review Board of Jagadguru Sri Shivarathreeshwara Hospital, India. This study was conducted in accordance with the Declaration of Helsinki. Written informed consent was obtained from the patient.
Declaration of patient consent
The authors certify that they have obtained the patient consent form. In the form, the patient has given his consent for his images and other clinical information to be reported in the journal. The patient understands that his name and initial will not be published and due efforts will be made to conceal his identity.
This study followed the Recommendations for the Conduct, Reporting, Editing and Publication of Scholarly Work in Medical Journals developed by the International Committee of Medical Journal Editors.
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