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CASE REPORTS

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Ipsilateral Ankle, Talus, and Calcaneus Fracture Dislocation: ACase Report

Erik Lund, MD and Hassan Mir, MD, MBA, FACS

Summary: Foot and ankle injuries can present with multiplefractures after high-energy trauma. The goal for complexcombined injuries remains anatomic restoration of articularsurfaces and overall alignment. Operative fixation may requirea variety of plate and screw sizes for an optimal construct. Belowis a case report of a combined injury involving fractures of theankle, talus, and calcaneus, where an assortment of mini-fragmentimplants were used.

Key Words: ankle, calcaneus, talus, fracture, mini fragment

INTRODUCTIONHigh-energy trauma to the foot and ankle presents a challenge

to the treating orthopaedic surgeon. Soft-tissue, ligamentous, andosseous components can form a constellation of complex injuries.Axial load, twisting, or combined mechanisms of injury can causefractures from the ankle to the forefoot. Temporization with closedreduction and splinting, percutaneous pinning, or external fixationmay be required before definitive fixation. Once soft-tissue swellingand fracture blisters subside, one can safely proceed with surgicalincisions. Preoperative planning for fixation may require a myriadof approaches, implant sizes, and designs. Because of the variationin the bone size and complex articular architecture, a surgeon may

ideally use mini, small, or rarely large fragment plates and screws fora well-implemented fixation construct. We present a case report ofa rare combination of injuries including an ipsilateral ankle, talus,and calcaneus fracture dislocations that required strategic planningand treatment with open reduction internal fixation.

PATIENT INFORMATIONPatient 1 is a 28-year-old womanwith amedical history significant

for intravenous drug abuse, hepatitis C, and opioid abuse who wasa restrained driver in a motor vehicle accident. She sustained isolatedleft lower extremity injuries. No other associated injuries occurred.She was evaluated in the trauma bay and found to have a closed grossdeformity of the foot and ankle with superficial abrasions. Herexamination showed intact neurovascular status of the limb. Radio-graphs and computed tomography (CT) revealed a complex pattern ofinjuries including a left bimalleolar ankle fracture [supinationadduction (SA) pattern], with an associated medial subtalar fracturedislocation plus a talar body fracture and an intra-articular calcaneusfracture (Figs. 1–3). In the emergency department, the ankle and sub-talar jointswere reduced and splinted. Shewas admitted and scheduledfor temporizing versus definitive fixation depending on soft tissuestatus in the operating room the following day.

SURGICAL TECHNIQUEAt the time of surgery, the skin wrinkled with gentle pressure, so

definitive fixation was undertaken (Fig. 4). The patient was supinewith a tourniquet and bump under the left hip on the operative side.Medial and lateral curvilinear approaches were made to the ankle,with care to avoid damage to neurovascular structures. Startingon the lateral side, working through the sinus tarsi, and around theperoneal tendons, the calcaneus fracture was visualized (Fig. 5).There was a large posterior facet fracture, which was reduced andprovisionally pinned. There were also an anterior process and lateralwall fractures. The calcaneal fracture lines were anatomicallyreduced and provisionally pinned. The calcaneuswas stabilized witha mini-fragment 2.7 mm Y-shaped plate and screws. After this,

From the Orthopaedic Trauma Service, Florida Orthopaedic Institute,Tampa, FL.

H. Mir is a consultant for Smith & Nephew, Zimmer Biomet, and Or-thoGrid. The remaining author reports no conflict of interest.

Reprints: Hassan Mir, MD, MBA, FACS, 5 Tampa General Circle, Suite710, Tampa, FL 33606 (e-mail: hmir@floridaortho.com).

The views and opinions expressed in this case report are those of theauthors and do not necessarily reflect the views of the editors of Journalof Orthopaedic Trauma or Smith & Nephew, Inc.

Copyright © 2018 Wolters Kluwer Health, Inc. All rights reserved.

DOI: 10.1097/BOT.0000000000001144

J Orthop Trauma � 2018 www.jorthotrauma.com e1

attention was directed medially. The medial malleolus fracture wasrotated distally on its soft tissue attachments for visualization of theposteromedial talar body fracture. There were some comminutedosteochondral fragments that were nonreconstructable and therefore

excised. The major talar body fracture was reduced and then fixedwith 2 countersunkmini-fragment lag screws. Themedial and lateralmalleoliwere then reduced anatomically andprovisionally pinnedonthe medial and lateral sides. The fibula fracture was a transverse

FIGURE 1. Left ankle anteroposteriorand lateral radiographs of the injury.

FIGURE 2. Left ankle after closedreduction and splinting in the emer-gency department.

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fracture and therefore was fixed with an intramedullary lag screw.The medial malleolus fracture was vertically oriented and thereforefixed with a buttress plate and multiple interfragmentary screws.Verification with direct visualization and multiplanar C-arm fluoro-scopic imaging was performed to ensure that all articular reductionswere anatomic and that all implants were well positioned. Bothmedially and laterally, the ankle joint capsule was repaired. Thesuperficial deltoid was repaired medially, and the anterior talofibularligament was repaired laterally. Medially, the posterior neurovascu-lar bundle and the posterior tibialis tendon had been retracted to

protect the structures throughout the case; however, at conclusion,they were placed back into their anatomic location, and the posteriortibialis tendon sheath and pulley were repaired. The deep tissueswere also reapproximated with 0Vicryl, and all skin was closed with2-0 Vicryl and 3-0 nylon under no tension. A well-padded short legsplint was placed. The patient was instructed to remain nonweight-bearing for 12 weeks.

The patient began range of motion exercises at 3 weekspostoperatively once her splint and sutures were removed, andshe was transitioned to a removable fracture brace. She remained

FIGURE 3. Axial, coronal, and sagittal CT images of the injury after closed reduction and splinting.

Ipsilateral Ankle, Talus, and Calcaneus Fracture Dislocation

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compliant with nonweightbearing for the recommended 12 weeksand then was transitioned to a walking boot and then a normal shoe.Her wounds healed without complication. The patient went ontouneventful union.

DISCUSSIONKS’s case presents several concomitant complex injuries. A

review of the literature identified several previously published casereports of combined injuries at 2 of the 3 locations (ankle, talus, orcalcaneus).1–5 One report does describe a similar case involvinga medial malleolar, talar, calcaneal, and cuboid fractures.6 Fortu-nately, all injuries to our patient were safely managed in one oper-ation. The soft tissues allowed early definitive fixation the day afterinjury. Often swelling precludes early open reduction internalfixation and requires temporizing fixation and elevation for daysor weeks. The utility of each incision wasmaximized by addressing

more than one fracture through each approach.Because of the sizedifferences at each anatomic location and with articular comminu-tion, fixationmay demand 2.0mm, 2.4mm, and 2.7mm screws andplates. The benefit of a set that contained a variety of screws, plates,and instruments of all 3 sizes facilitated care in this case.

Our patient’s ankle fracture fits the classification of a SA mech-anism of the Lauge–Hansen system.7 SA fractures require closeevaluation for medial plafond articular impaction and potentialneed for reduction and fixation.8 Up to 61%of these injuries sustainmarginal impaction of the medial tibial plafond, according toa recent CT study of 120 ankles injuries.9 Operative techniques forfixation of medial malleolus fractures abound, ranging from in-terfragmentary screws alone to plate fixation or tension band withK-wires.10,11 Biomechanically for SA ankle fractures, surgeonscommonly use an antiglide plating technique. At least 2 bio-mechanical reports have demonstrated that an antiglide plate with

FIGURE 4. Intraoperative fluoroscopy of the final fixation construct.

FIGURE 5. Three months post-operative left ankle mortise, lateral,and calcaneal axial views.

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an additional screw in the distal fragment is stronger under axialload.12,13 However, mini-fragment plating has been shown to be asstrong under tension and even stronger under axial load than lagscrews or tension band.11

The talar body fracture in our patient included a primaryfracture line and comminution. Talus fractures occur as 3%–6%ofall fractures in the foot, and 40% of all talus fractures involve thebody.2 A large level 1 trauma center series the incidence of oper-ative talar body fractures relative to all operative fractures is0.62%.14 Talus fractures may present up to 23% of the time withan associated adjacent fracture, with a calcaneus fracture in 6%–

11% of cases, or an ankle fracture in 15%–44%.2,3,15 Talar bodyfractures can lead to variable clinical and radiographic outcomes.Vallier et al14,15 reported osteonecrosis in 26% of talar body frac-tures, with 22% sustaining collapse. The same authors reportedthat 83% of talar body fractures led to one or more adjacent jointdeveloping radiographic posttraumatic arthritis, with subtalararthritis in 57% and tibiotalar arthritis in 61%. Depending onthe severity of injury, poor clinical outcomes can result, requiringsalvage fusion or even amputation. In a series of 45 patients withhigh-energy ipsilateral talus and calcaneus fractures, 5 went ontoearly below-the-knee amputation and another 5 primary subtalararthrodesis.6

Calcaneus fractures typically occur from a high-energymechanism of injury, with an estimated incidence of 2% of allfractures and 60% of tarsal fractures.16 Severity and outcome ofdisplaced intra-articular calcaneus fractures varies widely de-pending on the amount of energy and injury imparted throughthe calcaneus and subtalar joints17,18 The most prognostic classi-fication system to date incorporates the number of displaced pos-terior facet fragments based on CT of the injury in the coronalplane (the Sanders Classification).19 Sanders II–IV fractures haveworse functional outcome scores and higher incidence of latesubtalar fusion for symptomatic posttraumatic arthritis.17–19

Associated injuries occur often, with at least 10% sustaining a spi-nal compression fracture, 10% bilateral calcaneal fractures, anddoubling the length of hospital stay.20,21 Numerous authors haveinvestigated which variables affect patient-reported outcomes.One group found significantly worse health-related quality of lifewith increasing age, female sex, psychiatric history, and higherAspirin, but not with associated injuries, socioeconomic status, orinterestingly severity of injury.22

Operative technique for displaced intra-articular calcaneusfractures has evolved over time as well. For severe articularcomminution and step-off, the extensile lateral approach offersbroad exposure to the subtalar joint and lateral calcaneus.Through this approach, one can visualize and fixate articularand body fractures. Articular reduction in a series of 108 fracturestreated with an extensile lateral approach allowed for 103anatomic reductions.17 However, postoperative wound healingremains the primary concern with an extensile lateral approach,even with attention to detail, retractor placement, and “no touch”techniques. An alternative surgical approach is through the sinustarsi, with lower rates of wound complications.23,24 In a series of25 patients treated through a sinus tarsi approach, only 2 requiredopen debridement for surgical site infection.25 A meta-analysisof extensile lateral versus sinus tarsi approaches, including 2randomized control trials and 5 cohort studies, found fewerwound complications in the sinus tarsi patients, with similar clin-ical and radiographic outcomes.24

CONCLUSIONHigh-energy trauma can inflict significant injury to the foot

and ankle and subsequent morbidity to the patient. Close clinicaland radiographic evaluation will determine the extent of injury andguide treatment. Once soft-tissue swelling allows, one can considerdefinitive fixation of multiple fractures and injuries in a singlesetting through carefully planned surgical approaches and fixationstrategy. Because of the osseous dimensions of the foot and ankle,especially with articular involvement, optimal fixation may befacilitated by mini-fragment screws and plates of different shapesand sizes.

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2. Higgins TF, Baumgaertner MR. Diagnosis and treatment of fractures ofthe talus: a comprehensive review of the literature. Foot Ankle Int. 1999;20:595–605.

3. Gregory P, DiPasquale T, Herscovici D, et al. Ipsilateral fractures of thetalus and calcaneus. Foot Ankle Int. 1996;17:701–705.

4. Seybold D, Schildhauer TA, Muhr G. Combined ipsilateral fractures oftalus and calcaneus. Foot Ankle Int. 2008;29:318–324.

5. Mechchat A, Bensaad S, Shimi M, et al. Unusual ankle fracture: a casereport and literature review. J Clin Orthop Trauma. 2014;5:103–106.

6. Aminian A, Howe CR, Sangeorzan BJ, et al. Ipsilateral talar and calcanealfractures: a retrospective review of complications and sequelae. Injury.2009;40:139–145.

7. Lauge-Hansen N. Fractures of the ankle. II: combined experimental-surgical and experimental-roentgenologic investigations. Arch Surg.1950;60:957–985.

8. McConnell T, Tornetta P III. Marginal plafond impaction in associationwith supination-adduction ankle fractures: a report of eight cases. J OrthopTrauma. 2001;15:447–449.

9. Alluri RK, Hill JR, Donohoe S, et al. Radiographic detection of marginalimpaction in supination-adduction ankle fractures. Foot Ankle Int. 2017;38:1005–1010.

10. Toolan BC, Koval KJ, Kummer FJ, et al. Vertical shear fractures of themedial malleolus: a biomechanical study of five internal fixation techni-ques. Foot Ankle Int. 1994;15:483–489.

11. Amanatullah DF, McDonald E, Shellito A, et al. Effect of mini-fragmentfixation on the stabilization of medial malleolus fractures. J Trauma AcuteCare Surg. 2012;72:948–953.

12. Jones DA, Cannada LK, Bledsoe JG. Are hook plates advantageous com-pared to antiglide plates for vertical shear malleolar fractures? Am J Or-thop (Belle Mead NJ). 2016;45:E98–E102.

13. Dumigan RM, Bronson DG, Early JS. Analysis of fixation methods forvertical shear fractures of the medial malleolus. J Orthop Trauma. 2006;20:687–691.

14. Vallier HA, Nork SE, Benirschke SK, et al. Surgical treatment of talarbody fractures. J Bone Joint Surg Am. 2003;85-A:1716–1724.

15. Vallier HA, Reichard SG, Boyd AJ, et al. A new look at the Hawkinsclassification for talar neck fractures: which features of injury and treat-ment are predictive of osteonecrosis? J Bone Joint Surg Am. 2014;96:192–197.

16. Eastwood DM, Gregg PJ, Atkins RM. Intra-articular fractures of the cal-caneum. Part I: pathological anatomy and classification. J Bone Joint SurgBr. 1993;75:183–188.

17. Sanders R, Vaupel ZM, Erdogan M, et al. Operative treatment of displacedintraarticular calcaneal fractures: long-term (10–20 Years) results in 108fractures using a prognostic CT classification. J Orthop Trauma. 2014;28:551–563.

18. Csizy M, Buckley R, Tough S, et al. Displaced intra-articular calcanealfractures: variables predicting late subtalar fusion. J Orthop Trauma. 2003;17:106–112.

19. Sanders R, Fortin P, DiPasquale T, et al. Operative treatment in 120displaced intraarticular calcaneal fractures: results using a prognostic com-puted tomography scan classification. Clin Orthop Relat Res. 1993:87–95.

20. Gamal O, Shams A, El-Sayed Semaya A. A protocol for percutaneoustransarticular fixation of Sanders type II and III calcaneal fractures with or

Ipsilateral Ankle, Talus, and Calcaneus Fracture Dislocation

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without an added mini-open approach. J Foot Ankle Surg. 2016;55:1202–1209.

21. Buckley R, Tough S, McCormack R, et al. Operative compared withnonoperative treatment of displaced intra-articular calcaneal fractures:a prospective, randomized, controlled multicenter trial. J Bone Joint SurgAm. 2002;84-A:1733–1744.

22. Alexandridis G, Gunning AC, Leenen LP. Health-related quality of life intrauma patients who sustained a calcaneal fracture. Injury. 2016;47:1586–1591.

23. Kline AJ, Anderson RB, Davis WH, et al. Minimally invasive techniqueversus an extensile lateral approach for intra-articular calcaneal fractures.Foot Ankle Int. 2013;34:773–780.

24. Yao H, Liang T, Xu Y, et al. Sinus tarsi approach versus extensile lateralapproach for displaced intra-articular calcaneal fracture: a meta-analysis ofcurrent evidence base. J Orthop Surg Res. 2017;12:43.

25. Nosewicz T, Knupp M, Barg A, et al. Mini-open sinus tarsi approachwith percutaneous screw fixation of displaced calcaneal fractures:a prospective computed tomography-based study. Foot Ankle Int.2012;33:925–933.

Read the rest of the JOT Case Reports online on www.jorthotrauma.com. It’s the Grand Rounds series from the Jour-nal of Orthopaedic Trauma, the official journal of the Ortho-paedic Trauma Association.

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