Norio Usami

Classification of Fractures of the Talus: Clear Differentiation Between Neck and Body Fractures

The treatment and prognosis of neck fractures (extra-articular) and body fractures (intra-articular) of the talus are different. Ratios between neck fractures and body fractures reported by different investigators vary widely (from 6:1 to 1:1), because it is difficult to differentiate fractures crossing the anteromedial aspect of the trochlea. We examined 215 fractures of the talus. By examining the inferior surface fracture line, we found that the 61 fractures crossing the anteromedial aspect of the trochlea could be differentiated into 28 neck fractures and 33 body fractures. We suggest classifying fractures of the talus based on the inferior, not superior, surface fracture line.

Long-term follow up of talus fractures

Eighty-six patients who had experienced a fracture of the talus more than 10 years previously were assessed. The fracture had occurred in the neck of the talus in 52 feet and in the body of the talus in 27 feet. The fracture was complicated by dislocation in 47 feet, and aseptic necrosis had developed in 33 feet. The outcome was rated as excellent in 20 feet, good in 43, fair in 18, and poor in 7. The cause of poor outcome in the late stage was posttraumatic osteoarthritis secondary to avascular necrosis and incongruity of the joint surface. Early active exercise without weight bearing is recommended to prevent contracture and bone atrophy due to disuse, which may promote osteoarthrosis. Arthrodesis is recommended in patients with pain because the outcome is greatly improved by arthrodesis, even when performed more than 10 years after the injury.

Calcaneal fractures in children.

Calcaneal fractures are rare in children but frequent in adults. We report 18 cases (20 feet) of pediatric calcaneal fractures before the distal tibial growth line closed to assess the characteristics of pediatric calcaneal fractures and reveal differences in treatment and prognosis between children and adults. Twelve (60%) of the fractures were extraarticular, a higher percentage than in adults, and only four (20%) were intraarticular fractures associated with displacement. One case of avulsion fracture of the portion of the calcaneus where the Achilles tendon inserts, in which there was large displacement, and one intraarticular fracture were treated surgically. The outcome was good, including the surgical cases. One of the reasons that calcaneal fractures are considered rare in children is that they are missed, and thus care is required in making the diagnosis.

Closed complete rupture of the flexor hallucis longus tendon at the groove of the talus.

A rare case of closed complete rupture of the flexor hallucis longus tendon at its groove in the posterior process of the talus is reported in a soccer player who developed pseudarthrosis of the posterolateral tubercle of the talus after a Shepherds fracture. Partial rupture or tenosynovitis of the flexor hallucis longus tendon at this level is well known in classical ballet dancers and soccer players. Three cases of complete rupture of the flexor hallucis longus tendon near the metatarsophalangeal joint and three under the sustentaculum tali have been reported, but there have been no reports at the groove of the talus. Repair was accomplished by tendon graft, and active flexion of the interphalangeal joint is now possible.

Anterior Subtalar Dislocation: Case Report

Anterior subtalar dislocations are extremely rare. To our knowledge, only four cases have been reported in detail in the literature. A diagnosis of anterior subtalar dislocation should be confirmed by an anteroposterior view radiograph because lateral subtalar dislocation always includes some anterior displacement of the mid-foot. We report a case of anterior subtalar dislocation confirmed by both lateral and anteroposterior view radiographs and discuss its pathomechanism, diagnosis, and treatment.

Fractures of the body of the talus in the sagittal plane

Abstract Fractures of the body of the talus in the sagittal plane are very rare. The definition, however, is unclear. We therefore reviewed nine cases of this type of fracture in our series. The rate of occurrence was 4.6% of major talar fractures. Analysis of radiographys revealed a characteristic fracture line which follows a particular path from the lateral entrance of the sinus tarsi to the sulcus of the flexor hallucis longus on the inferior surface of the talus. Based on this finding, we re-defined sagittal fractures of the talar body on the basis of this distinctive fracture line. This line corresponds to the structural weak point of the talus. Thus, concentration of stress at this point may cause either sagittal body fractures or talar neck fractures.

Stress fractures of the proximal phalanx of the great toe

Abstract Stress fractures of the proximal phalanx of the great toe are very rare. We have encountered such fractures in four patients with no clear history of injury. The patients consisted of one male and three female high-level athletes. All were in their teens but their epiphyseal line had already closed. The three women exhibited a tendency toward hallux valgus. Three of the four patients were treated conservatively by local rest for several months. The other patient was treated surgically because she was not able to continue resting and pseudarthrosis had occurred. Surgical findings revealed that the fracture had occurred on the medial aspect of the plantar side of the proximal phalanx of the great toe and that no ligaments or tendons were attached to the fragment. This suggested that the cause of this fracture was not tension by ligaments but the shear force generated by striking the ground.

Four toes dislocation at the metatarsophalangeal joint

Abstract Dislocation of the four medial toes at the metatarsophalangeal joint (MTPJ) has not been previously reported. The patient was a 35-year-old man who sustained the injury in a motorcycle accident. Manual reduction was easily performed but maintenance of reduction was difficult. Ten years later, osteoarthritic changes at the MTPJs were present with severe limitation in activities of living.

Juvenile hallux valgus in Japan: a radiographic comparison with older age groups

Abstract The feet of 215 female patients were studied in order to make a comparison of hallux valgus deformity between patients in their teen years and older patients. Significant differences were found in the intermetatarsal angle between the 1st and 5th metatarsals (IM 1–5A) between patients in their 20s and those in their 60s. A significant difference was also found in the hallux valgus angle between patients in their teens and those in their 50s. Looking at the correlation between the intermetatarsal angle between the 1st and 2nd metatarsals (IM 1–2A) and the hallux valgus angle, it was found that the correlation was weaker among the teen patients than among older patients.

Fractures of the lateral process of the talus

Abstract Thirteen patients with isolated fractures of the lateral process of the talus were reviewed. Two fracture types were seen: an intra-articular type in seven cases and an avulsion type in six cases. The former occurs at the base of the process as a result of blows to the calcaneus. The latter occurs at the tip as a result of traction by ligaments. Open reduction and internal fixation were performed in four cases of displaced intraarticular-type fracture and in one case of unstable avulsion type fracture. Bone union was complete, and the results were good in every case. However, pain on walking persisted in two cases treated conservatively. It was suspected that many isolated fractures of the lateral process of the talus are misdiagnosed as severe sprain and cause persistent ankle pain. Thus, accurate diagnosis and appropriate treatment in the early stages are essential to prevent persistent symptoms.