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. 2014;34:175–180.

A Pediatric Comminuted Talar Fracture Treated by Minimal K-Wire Fixation Without Using a Tourniquet

Sermet Inal 1, Canan Inal 2
PMCID: PMC4127733  PMID: 25328479

Abstract

Background

Pediatric comminuted talar fractures are reported to be rare, and treatment options such as minimal internal K-wire fixation without using a tourniquet to prevent avascular necrosis have not previously been investigated.

Case Description

We report a case of a comminuted talar body and a non-displaced neck fracture with dislocation of the tibiotalar, talonavicular and subtalar joints with bimalleolar epiphyseal fractures in an 11-year-old boy due to a fall from height. We present radiological findings, the surgical procedure and clinical outcomes of minimal internal K-wire fixation without using a tourniquet.

Literature Review

Avascular necrosis rates are reported to be between 0 % and 66 % after fractures of the neck of the talus and the talar body in children. The likelihood of developing avascular necrosis increases with the severity of the fracture.

Clinical Relevance

To avoid avascular necrosis in a comminuted talar fracture accompanied by tibiotalar, talonavicular, subtalar dislocations and bimalleolar epiphyseal fractures, a minimal internal K-wire fixation without the use of a tourniquet was performed. The outcome was evaluated by the American Orthopedic Foot and Ankle Society score (AOFAS). A score of 90 (excellent) was found at the end of the second year of follow up. Radiology revealed preservation of the joint with no evidence of avascular necrosis, and clinical findings revealed a favorable functional outcome after two years.

Level of Evidence

4

Keywords: talus, fracture healing, tourniquets, avascular, necrosis

Introduction

Talar body fractures are rare in children with an incidence of less than 0.08 %1-4. Fractures of the neck of the talus are more common and usually have a better prognosis than talar body fractures5-7. Jeremy et al. reported a talar neck:talar body ratio of 17:13 in a series of 33 cases of pediatric talar fractures8. The mechanism of injury for pediatric talus fractures is usually a fall from height with a forced extension injury at the ankle with some supination component, resulting in associated malleolar fractures6. An increasing likelihood and severity of complications, such as avascular necrosis and arthrosis, have been reported in literature with respect to the severity of the fracture or fracture dislocation6. In addition, it has been suggested that children older than 10 years with talar fractures should be treated according to the same treatment principles as fractures in adults, especially with open reduction and internal fixation6,9. Here, we report a case of an 11-year-old child in which we did not use internal fixation or a tourniquet during the operation. To our knowledge, no other reports have used minimal internal percutaneous K-wire fixation without using a tourniquet to treat talar fractures in children older than 10 years.

The most significant complications arising from surgery are avascular necrosis (AVN) and posttraumatic malalignment with subsequent arthritis4,10,11. In the past, many authors thought that AVN of the talus would not appear after pediatric trauma12. Now, however, many authors believe that AVN of the talus can occur in children and that it is the main cause of disability after a fracture of the talus13,14. It is known as the most common complication with regards to talar fractures in children2,8. The available literature for therapy and outcomes after talar fractures in children is sparse and consists mainly of descriptive series with small patient numbers3,8,15. Therefore, it is very important to develop a clear therapy regimen. To do so, long-term follow-up after this injury is necessary16. The research question in this study was whether minimal internal K-wire fixation without using a tourniquet might prevent AVN and improve functional outcome. We therefore treated a talar injury with minimal internal K-wire fixation without using a tourniquet and followed up with the patient after two years.

Case Report

An 11-year-old male patient presented to our emergency department one hour after falling from five meters onto his left ankle. The foot was deformed and capillary recirculation of the lateral side of the ankle was delayed. Radiographs and CT scan of the ankle revealed a comminuted talar body, non-displaced talar neck fracture and bimalleolar epiphyseal fracture with dislocation of the talonavicular, tibiotalar and subtalar joints (Figures 1 a, b, c). The injury was classified as a type 5 crush fracture of the talus according to Delee17.

Figure 1 a, b, c. AP, lateral X-rays and CT of fracture-dislocation patterns. Talonavicular, subtalar dislocation and a non-displaced talar neck fracture were visualized by tomography.

Figure 1 a, b, c

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Surgical treatment was performed as early as possible. With medial and anterolateral approaches, an open reduction and percutaneous multiple K-wire fixation were performed without using a tourniquet (Figures 2 a, b, c). The patient was discharged wearing a long leg cast. After 1.5 months, the long leg cast was shortened below the knee. The cast and K- wires were removed after 2.5 months when radiological union of the fractures was evident (Figure 3 a, b). Active and passive ankle exercises were started at this time, however, total axial loading was not allowed until four months after the injury. The patient was pain free and the ankle had nearly full range of motion six months after the injury. The outcome was evaluated by the American Orthopedic Foot and Ankle Society score (AOFAS). The patient's AOFAS was 90, an excellent score, at the end of the second year. Control Radiographs at two-year follow-up showed no signs of AVN (Figures 4 a, b).

Figure 2 a, b, c. Postoperative AP, lateral and oblique X-rays.

Figure 2 a, b, c

Figure 2 a, b, c

Figure 2 a, b, c

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Figure 3 a, b. AP and lateral radiographs demonstrating fracture union.

Figure 3 a, b

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Figure 4 a, b. AP and lateral X-rays of the ankle 2 years after operation. Union was complete and no sign of avascular necrosis was seen in radiographs.

Figure 4 a, b

Figure 4 a, b

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Discussion

A fracture through the body of the talus is less common than talar neck fractures in both adults and children and generally carries a worse prognosis, especially when displaced. Emergency open reduction and fixation is required in the displaced fracture to prevent AVN and early degenerative osteoarthritis. Fractures of the body of the talus were first classified in 1977 by Sneppen et al.18, and later modified by Delee17 into a five-part classification: type 1, transchondral dome fractures; type 2, shear fractures; type 3, posterior tubercle fractures; type 4, lateral process fractures; and type 5, crush fractures. According to this classification, our case was a type 5 crush fracture. Interestingly, the fracture pattern was not compatible with the Hawkins classification because the talus neck fracture was a non-displaced fracture with associated dislocation of tibiotalar, subtalar and talonavicular joints13, whereas a talar neck fracture must be displaced to be classified under the Hawkins system.

Yazdi and Ramezan Shirazi19 reported that talar fractures are extremely rare in children. The main reason for the low incidence of this injury could be a higher elastic resistance of the immature bone in this age group, which they attributed to the unusual presentation of the fracture. Meier et al.16 also reported this point in their study.

Although the treatment of children older than 10 years should be similar to the treatment of adults with talar fractures, we treated our patient using percutaneous K- wires instead of internal fixation, which is the method of choice for children. This treatment approach was employed, at least in part, because the fracture pattern of the talus was comminuted and was not suitable for internal fixation devices.

Eberl et al.2 reported that even when there is no apparent difference in the cause of the trauma leading to fractures of the talus, adolescents present with more severe fractures of the talus compared with children younger than 12 years. Furthermore, they observed that AVN is not persistent and resolved at follow up in patients younger than 12 years and patient outcome is favorable in most cases irrespective of the mode of treatment.

Some authors declared that complications including pain, AVN, and osteoarthritis are common following open reduction and internal fixation of the fracture20. Long-term complications may become a more significant problem in the pediatric age group as a result of longer life expectancy16. It seems that anatomic reduction and internal fixation of displaced talar fractures have key roles in lowering complication rates.

AVN is the most critical complication following talar fracture and is well described in adults; its incidence is directly related to the location of the fracture, fracture- dislocation and the amount of fracture displacement5,6,13. The reported incidence of AVN with fractures of the talar neck is 0 - 10 % for type 1 fractures, 40 - 50 % for type 2 fractures, 80 - 90 % for type 3 fractures and 100 % for type 4 fractures5,6,13. Relatively, little is known about the pediatric talar fractures, as there is only a few series in the literature. These were determined predominantly from adult populations and may not reflect the true incidence of AVN in the pediatric population. In addition, newer treatment techniques such as earlier reduction with stable internal fixation of these displaced fractures may improve results21.

In review of the literature, the few reports on pediatric talar fractures offer conflicting data with respect to AVN. Letts and Gibbeault7 reported a 25% incidence of AVN in 12 patients; however, two of these three patients had non-displaced fractures that were undiagnosed at the time of fracture and AVN developed later. Similarly, Linhart and Hollwarth22 reported a 27 % incidence of AVN in children, some of whom also had non-displaced fractures. Mazel et al.23 reported that two of seven children older than 6 years with complete talar neck fractures developed AVN at a later time. In contrast, Jensen et al.14 reported no occurrence of AVN in 11 cases of non-displaced fractures and three cases of displaced talar fractures in children.

Blood supply to the talus is very important and well described in literature. It is susceptible to disruption following the displacement of the talar neck or body fracture with subsequent development of AVN. There are four main sources of extraosseous blood supply: the deltoid branch of the posterior tibial artery, the artery of the tarsal canal, the branches of dorsalis pedis artery and the artery of the tarsal sinus. These arteries normally provide a significant intraosseous blood supply within the talus; however, the blood supply becomes compromised in displaced and comminuted fractures 24-27.

When the talus fractures, the vessels become disrupted; until reduction is performed, reperfusion does not occur completely. For this reason, ischemia occurs between the occurrence of the fracture and reduction of the talus. Longer ischemic time may lead to osteonecrosis of the talus. Application of a tourniquet, which lengthens ischemic time, can therefore be a negative factor for blood supply and can contribute to subsequent osteonecrosis. In fact, improper use of a tourniquet can lead to arterial injury, muscle injury, and edema28,29,30,31.

Due to complications associated with the use of tourniquets, the recommended maximum time for their use is two hours. A pH of 6.9, which corresponds to the fatigue point of muscle, and lower may produce irreversible damage that leads to postoperative muscle weakness. Histology generally shows changes after one hour, but muscle degeneration and cell necrosis occur after two to three hours. Therefore, it can be concluded that there is no safe maximum tourniquet time and the safest time is the shortest time28,29,30,31.

The Hawkins sign is described as radiolucency in the subchondral area and indicates that the body of the talus has not undergone avascular processes. If the Hawkins sign is present, there is a high probability that the talar body has a good blood supply and will remain viable. This sign presents six to eight weeks after injury. We saw this sign four weeks after injury and therefore decided not to perform an MRI or scintigraphy at the early postoperative period, which could be considered a limitation of our study (Figure 5).

Figure 5. The Hawkins sign of the talus in AP and lateral radiographs.

Figure 5

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There has been no other case report of unusual presentation of comminuted talar fracture dislocation in a child. The use of a tourniquet for this kind of comminuted talar fracture may contribute to avascular necrosis in the talus.

Acknowledgments

The Hawkins sign of talus in this case report is presented as a poster presentation at the 33 International Congress of Turkish Radiology Society.

Conflict of Interest

The authors declare that they have no conflicts (including financial, consultant, institutional and other relationships) of interest.

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