|Year : 2017 | Volume
| Issue : 3 | Page : 185-187
Unusual talus fracture in a pediatric patient
Ibrahim Ali Albrahim
Department of Orthopaedic, College of Medicine, Imam Abdulrahman Bin Faisal University, Dammam, Kingdom of Saudi Arabia
|Date of Web Publication||6-Feb-2018|
Dr. Ibrahim Ali Albrahim
Department of Orthopaedic, College of Medicine, Imam Abdulrahman Bin Faisal University, Dammam 31431
Kingdom of Saudi Arabia
Source of Support: None, Conflict of Interest: None
Talus fracture in pediatric age is very rare due to the higher elasticity of skeletally immature bone in comparison to the adult bone. The usual mechanism of these types of fractures is a fall from height with the foot in dorsiflexion position. We are presenting a case report for a pediatric patient with comminuted talar body and talar neck fracture which was treated nonsurgically with cast immobilization and his outcome in 2 years follow-up.
Keywords: Nonsurgical management, pediatric, talus fracture
|How to cite this article:|
Albrahim IA. Unusual talus fracture in a pediatric patient. Saudi J Health Sci 2017;6:185-7
| Introduction|| |
In skeletally immature pediatric patients, talar fractures are very rare. This is due to the higher elasticity and lower brittle nature of pediatric bone when compared to the adult bone. As a reason for higher elasticity pediatric bone can tolerate higher force before they can get fractured.
The incidence for talus fracture accounts for 0.008% of all pediatric fractures in comparison with 0.3% in adults. Talar neck is the most common fracture followed by the talar body and last is the talar head.
The mechanism of injury is thought to be a sudden dorsiflexion on a partially plantar flexed foot, and usually, this happened from falling from height.
This is a case presentation of a pediatric patient with a talar body and neck fracture which was treated nonoperatively with a cast immobilization which is uncommon treatment method and his outcome in 2 years follow-up.
| Case Report|| |
A 9-year-old boy presented to the emergency department after a history of falling from around 7 m height while he was playing at home.
The patient was complaining of bilateral ankle pain and left leg pain and inability to weight bear on both legs. Medical and surgical history were unremarkable. Head to toe examination revealed multiple lacerations in the scalp with swelling and tenderness in the bilateral ankle with no wounds in the lower limbs, palpable distal pulses, and intact neurological examination.
Plain radiographs anteroposterior, lateral and mortise view was performed for both ankles showed Salter-Harris type 3 fracture of medial malleolus of right ankle and left fibula shaft fracture with comminuted talar body and talar neck fracture of the left ankle.
The initial management was admission of the patient for assessment, bilateral plaster of Paris backslabs with the ankles in 90° of dorsiflexion and elevation of the injured limbs, analgesia inform of morphine and paracetamol.
A computerized tomography (CT) scan was performed to the left ankle after the initial management and showed that the patient has talar neck fracture, Hawkins classification type 1, with comminuted fracture of the talar body involving the posterior and medial aspect of the body which was minimally displaced [Figure 1].
|Figure 1: Plain radiograph (mortise view) and computerized tomography scan (coronal and sagittal view) of left ankle showing talar neck Hawkins classification type 1 with comminuted fracture of the talar body involving the posterior and medial aspect of the body with minimal displacement|
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After studying the image and discussion with the family putting in mind that the talar neck and body comminution will not improve by surgical fixation, decision made for conservative management with below knee cast with close observation for complications.
The patient was taken to the operative room next morning where under general anesthesia close reduction and percutaneous K-wire fixation was done to the right ankle. For the left ankle, the talus fracture position was improved under image intensifier and below knee full cast was applied assuring no further displacement occurred.
The patient was kept in the pediatric ward for observation of the swelling, elevation, and analgesia for 2 days and he was discharged home in stable condition on wheelchair mobilization (nonweight bearing on both legs) with outpatient clinic follow-up.
The patient was followed in the clinic with routine ankle radiograph. The right ankle K-wire was removed at 6 weeks postoperation, and the left ankle cast was kept for 9 weeks after making sure that the fracture did not further displace with the good healing process.
After removing the cast, the patient has limited ankle range of motion bilaterally for that, he was given physiotherapy and to continue nonweight bearing for 2 weeks more before full weight baring mobilization.
At 6 months follow-up, the patient had no complaint. There was no pain, limitation of movement or impaired function of the left ankle (the talus fracture) and on examination, there were no deformities with full range of motion in both ankles and the radiographic image showed healed talus fracture with no signs of avascular necrosis.
At 2 years follow-up, the patient has no complained, patient has full range of motion in both ankles with American Orthopaedic Foot and Ankle Society Ankle-Hind-foot Scale of 100 points in total [Figure 2]. The radiographic image showed healed talus fracture with no signs of avascular necrosis [Figure 3].
|Figure 2: Clinical photos of the left ankle showing good plantigrade foot with painless full range of motion of left ankle|
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|Figure 3: Plain radiograph of left ankle 2 years after fracture showinghealed fracture, with no loss of height or malunion or signs of avascular necrosis|
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| Discussion|| |
Relatively little is known about pediatric talus fractures, as there are only a small number of series in the literature, the largest of which includes 29 fractures. Talar fractures in pediatric are rare because the talus is cartilaginous, making it much more flexible than that of the adult.
In our patient, the question of whether to fix or treat conservatively for the Talus fracture many authors agree that decision depends on the degree of displacement and dislocation of the talus.
In this case, the Talar neck and the Talar body fracture were comminuted and minimally displaced, and the decision was taken not to fix the fractures.
There are significant differences in the prognosis of the talus fracture between adult and pediatric patients. Sometimes, these injuries can be difficult to diagnose with plain radiograph, and further assessment with CT scan or magnetic resonance imaging may be necessary. Undisplaced or minimally displaced fracture of the talus is less likely to undergo osteonecrosis if undergo for conservative management.
Reviewing the literature showed that in a retrospective study by Eberl et al. they found that in 6 patients <12 years with nondisplaced or minimally displaced talus fracture that was treated nonsurgically no necrosis at follow-up (mean period 3.2 years) was detected in children.
Smith et al. concluded in 29 patients with an average age of 13.5 years with talus fracture that displaced pediatric talus fractures and fractures associated with high-energy trauma have more complications including arthrosis (17%), delayed union (3%), necrosis (7%) neuropraxia (7%), and the need of other surgery (10 %).
Avascular necrosis can occur in children as reported by Talkhani et al. but after fracture dislocation of talus or fracture with displacement.
The data available where fixation has been used show high incidences of complications, with osteonecrosis in 10 out of 26 cases and full talar body collapse in 5 of those 10.
In conclusion in skeletally immature patients, talus fractures are rare, and theses fractures are usually difficult to diagnose; hence, the use of further investigations inform of CT scan or magnetic reasoning imaging to help in clarifying the fracture.
The author advocates the use of nonoperative management in treating nondisplaced or minimally displaced pediatric talus fracture.
For displaced talus fracture or fracture-dislocation anatomical reduction with surgical fixation is advised. The patient should stay in the cast to immobilize the fracture with nonweight bearing mobilization with routine radiographic films follow-up in the clinic to make sure that the fracture did not displace and to make sure that evidence of healing has occurred. Although the data in the literature review in these rare type fractures still not enough, the great outcome after 2 years of follow-up our patient enhances our treatment plane and of course not forgetting the usual encouraging outcome in the skeletally immature patient even with severe injuries.
Declaration of patient consent
The authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
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[Figure 1], [Figure 2], [Figure 3]