Date: Mon, 26 Jan 2004 01:19:18 +0000
From: Jeff Richmond
Subject: Posteromedial Talus Fracture
These are CT cuts from a 23 year old firefighter who slipped on ice. What is the ideal surgical approach for fixing this? Posteromedial, posterior or trans-malleolar?
Thanks for the input.
North Shore University Hospital
Manhasset, New York
Date: Sun, 25 Jan 2004 22:52:36 -0600
From: Obremskey, William T
Standard medial approach b/t AT and PT. MM osteotomy at angle of joint and flip it down to see.
May need modular hand or mini-frag screws to reassemble.
William T Obremskey MD MPH
Orthopedic Trauma Division
131MCS 2100 Pierce Ave
Nashville, TN 37232-3450
Date: Mon, 26 Jan 2004 12:28:24 -0600
From: John Early
I would approach this fracture from the medial side. i find that most of these do not require a medial malleolar osteotomy and in fact can make it harder for the actual reduction and fixation. I would make the incision along the path of the posterior tibial tendon, actually free up the tendon from it sheath and displace it anteriorly over the malleolus. with sub periosteal dissection along the posterior portion of the medial malleolus and across the posterior aspect of the tibia the fracture is visualized. the FDL and bundle is retracted away from the malleolus. It is a small space but with dorsiflexion of the ankle the fracture is directly in the wound. manipulation of the piece or pieces may be difficult due to the attachment of the FHL sheath between the tuberosities. the capsule of the subtalar joint may need to be released if not already loose from the injury. Usually cancellous graft is needed to fill the void between the articular surfaces. percutaneous bone plugs from the calcaneus can be easily retrieved and are adequate. the comminution is usually in the subtalar joint area ans this needs to be cleared to give that joint a chance to survive.
the modular hand set has the best assortment of screw sizes and lengths to stabilize this fracture.
Post op I keep them still for 6 weeks and non-weight bearing for 3 months.
John Early MD
Orthopaedic Foot and Ankle Service
Univ Texas Southwestern Medical Center
Date: Mon, 26 Jan 2004 15:10:13 EST
I second Dr. Early's suggestion for approach. although I don't think we know "the ideal approach". The fracture pattern is not clear to me. It is a fracture of the postero-medialtalus body, as you said.
Image 19 is a saggital view showing a coronal plane fracture of the posterior 1/3 of the talus body. Image 24 is a coronal view showing a saggital plane fracture of the medial 1/3 of the talus body.
Images 20,21,22 are axial views showing coronal plane (slightly oblique)fracture of the posterior 1/5 of the talus body. It is hard for me to reconcile these images into an understanding of how big the fragments are and where they are located. Perhaps a 3 dimensional model would help. The comminution is also hard to assess. The axial views show at least 3 fairly large pieces. The coronal view (Image 24) shows a large central void perhaps due to impaction or comminution. Ideally, each fragment would have some kind of fixation from it to the main talus body but accomplishing that will not be easy. Knowing how many there are before you go in would be helpful.
In addition to the "modular hand set" some sort of bioabsorbable pins might be helpful since most of the talus body is covered with articular surface and the comminuted fragments may large enough to need fixing but too small to hold metal screws.