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Fractures of the Lateral Process of the Talus: A Diagnostic Challenge . A Tutorial for Optimizing Detection Julia Crim, MD Bradley Hale, MD University of Utah. Lateral Process Talus Fractures. Fractures can be subtle and difficult to see on plain radiographs.

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fractures of the lateral process of the talus a diagnostic challenge

Fractures of the Lateral Process of the Talus: A Diagnostic Challenge

A Tutorial for Optimizing Detection

Julia Crim, MD

Bradley Hale, MD

University of Utah

lateral process talus fractures
Lateral Process Talus Fractures
  • Fractures can be subtle and difficult to see on plain radiographs.
  • Fractures and their sequelae can lead to long-term debility.
  • Fractures are more common than previously thought.
  • A systematic approach to evaluation improves identification.
objectives of this presentation
Objectives of this presentation.

1. Review pertinent anatomy.

2. Review common mechanisms and patient presentation.

3. Review imaging techniques including radiographs, CT and MRI.

4. Increase awareness of subtle signs associated with these fractures.

lateral process of talus
Lateral Process of Talus

The superior margin of the lateral process is part of the lateral gutter of the ankle joint.

Posterior subtalar joint

The inferior margin of the lateral process forms the anterior portion of the posterior subtalar joint.

Calcaneus

Lateral process

As part of both the tibiotalar and posterior subtalar joints, the lateral process is important in many complex motions including inversion, eversion, dorsiflexion, plantarflexion and gliding.

lateral process on coronal ct
Lateral Process on Coronal CT

Lateral gutter

Posterior subtalar joint

radiograph of the lateral process
Radiograph of the Lateral Process

Tibia

Fibula

Talus

Lateral process

AP

mortise

mechanism of injury
Mechanism of Injury
  • Fracture occurs from inversion and dorsiflexion of foot .
    • Patients often present with ankle sprain.
  • Lateral process transmits compression force from tibia to calcaneus.
common causes of fracture
Common Causes of Fracture
  • Snowboarding
  • Fall from a height
  • Soccer
  • Occasionally MVA
fracture incidence
Fracture Incidence
  • Uncommon?
    • Lateral process fractures first reported 1942.
    • Mukherjee (1974) reported that lateral process fractures accounted for less than 1% of 1500 ankle injuries reviewed.
  • Or undetected?
    • Hawkins (1965): 26% of talus fractures
    • 40-50% of lateral process fractures not detected at time of injury (Hawkins, Mukherjee, Mills and Horne)
lateral process fracture
Lateral Process Fracture
  • Divided into three types
    • May be displaced or non-displaced

Type 2 –

Fracture through the base of the process

Type 3 –

Comminuted

Type 1 -

Chip fracture off tip of process

fracture treatment
Fracture Treatment
  • Cast
  • Screw fixation
  • Excision of comminuted fragments
prognosis of fracture
Prognosis of Fracture
  • Good with early ORIF
  • Poor with casting or delayed ORIF
prospective study of fx treatment
Prospective study of fx treatment
  • 23 intra-articular fractures with mean follow up of 24 months.
    • Functional outcome rating 0-100
    • 4 underwent early ORIF; 3 rated 100, 1 rated 93
    • 19 patients were casted
      • 4 rated 100
      • 15 rated 65-95
        • 11 complained of stiffness and/or pain with exercise
        • 4 unable to do activities of daily living

Paul CC, Janes PC. Snowboarder’s talus fx; Skiing trauma and safety: intl symposium 1996

potential complications
Potential Complications
  • Nonunion
  • Osteoarthritis of subtalar joint
  • Some may need subtalar arthrodesis
recommended imaging lateral process fx
Recommended Imaging: Lateral Process Fx
  • AP, Mortise, Lateral
    • The fracture may be visible on only one view
    • Radiographs underestimate extent of fracture
  • Broden’s with plantarflexion
  • Internal rotation & neutral flexion
  • Lateral tomography (obsolete)
  • CT, including reconstructions
  • MRI
radiographic findings
Radiographic findings
  • Visible fracture line or cortical step-off.
  • Non-visualization or decreased density of the tip of the lateral process.
  • Displacement or rotation.
  • Lateral soft tissue swelling, typically lower than seen in ankle sprain without fracture.
pitfalls in detection
Pitfalls in Detection
  • Fracture may be visible on only one view.
  • Radiographs may underestimate fracture.
    • If suspicious, go to CT or MRI.
radiographic finding 1 cortical step off
Radiographic finding 1:Cortical step-off

22 year old female soccer player reports twisting ankle during the game

Normal lateral process

radiographic finding 1 cortical step off21
Radiographic finding 1:Cortical step-off

22 year old female soccer player reports twisting ankle during the game

An oblique fracture with cortical step-off is seen through the anterior margin (blue arrow) of the lateral process. A subtle lucency is visible at the inferior margin (green arrow).

Normal

radiographic finding 2 non visualization of the tip of the process
Radiographic finding 2:Non-visualization of the tip of the process.

A young snowboarder.

Normal lateral process

The tip of the lateral process is indistinct and poorly visualized

radiographic finding 3 displacement
Radiographic finding 3:Displacement

Another snowboarder (snowboarding can be dangerous!)

Displaced fragment seen on both the AP (inferior displacement) and lateral projection (anterior displacement).

radiographic finding 4 soft tissue swelling
Radiographic finding 4:Soft tissue swelling

Fracture

STS

Fracture

STS

Radiographs from two separate patients with lateral process fractures. Note that soft tissue swelling is present laterally, but is more inferior than is typically seen in an ankle sprain or distal fibular fracture.

pitfall in detection fracture visible on only 1 view
Pitfall in detection: Fracture visible on only 1 view

Fell off ladder.

This fracture (which was initially missed) is seen only on the anterior projection where cortical irregularity is identified.

slide26
Pitfall in detection:Radiographs may underestimate extent of fracture. CT is recommended for any fracture larger than a flake.

Radiographs show fracture which appears to be through the tip of the process. However, CT (including reconstructions) shows the fracture to be much larger, extending into the base of the process. The posterior subtalar joint is extensively disrupted.

improving detection if suspicious mri may be helpful
Improving detection:If suspicious, MRI may be helpful.

Sag STIR

Initial radiographs interpreted as normal. Patient continued to have pain. MRI clearly shows fracture through the base of the process.

utah series
Utah Series
  • 14 intra-articular lateral process fractures over 8 month interval
  • Patient age range 18-35
  • 2 fractures initially missed by the resident physician, but detected on radiographs by the attending; 12 detected acutely on radiographs by the resident.
  • 7 had other associated fractures
  • 8 had CT, 1 had MRI
views on which fractures were visible
Views on which fractures were visible
  • Lateral only: 3 (including 1 missed fx)
  • Readily visible on lateral but difficult on AP: 2
  • Lateral and AP: 5
  • Lateral and mortise: 1
  • AP only: 1 (missed)
  • Seen on all views: 2
utah series associated fractures
Utah Series: Associated Fractures
  • 5 talus
    • 1 body
    • 2 neck
    • 1 head of talus*
    • 1 posterior process talus
  • 1 EDB origin avulsion
  • 1 nondisplaced central calcaneus*
  • 1 pilon *(seen on CT only)
final review
Final Review
  • In reviewing this presentation we hope you were able to :
    • Become more familiar with the anatomy of the talus
    • Become more aware of the significance of lateral process fractures
    • Review important signs of this fracture
    • Better understand pitfalls and how to minimize them
references
References
  • Hawkins LG. (1965) Fractures of the lateral process of the talus. J Bone Joint Surg. 47A:275.
  • Heckman JC, McLean MR. (1985) Fractures of the lateral process of the talus. Clin Orthop 199:108-113.
  • Higgins TF, Baumgaertner, MR. (1999) Diagnosis and treatment of fractures of the talus: A comprehensive review of the literature. Foot Ankle Int. 20(9):595-604.
  • Mills HJ, Horne G. (1987) Fractures of the lateral process of the talus. Aust N.Z. J. Surg. 57:643-646.
  • Mukherjee SK, Pringle RM, Baxter AD. (1974) Fractures of the lateral process of the talus. J. Bone Joint Surg. 56B:263
  • Paul CC, Janes PC. Snowboarder’s talus fx; Skiing trauma and safety: intl symposium 1996.