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Subtalar dislocation is an uncommon injury involving the simultaneous dislocation of the talocalcaneal and talonavicular joints. Radiographic images can be difficult to interpret for the inexperienced clinician because of the obliquity of the foot and the overlap of tarsal bones. The authors describe the case of a 24-year-old male who presented to the emergency department (ED) with a painful left foot and ankle following a twisting injury. He was examined by a junior member of the ED team and diagnosed with a left ankle sprain. Preparations were underway for discharge home when the radiographs, described as 'normal but somewhat strange', were shown to the orthopaedic senior house officer who happened to be in the ED. The patient was subsequently reviewed by the orthopaedic registrar and diagnosed with a medial subtalar dislocation. He was then taken to theatre for closed reduction and application of a below-knee cast.
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BMJ Case Reports 2011; doi:10.1136/bcr.04.2011.4086
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BACKGROUND
Subtalar dislocations are very rare injuries accounting for
1% of all dislocations
1
. They can be anterior, posterior,
medial or lateral based on the direction of displacement of
the foot on the calcaneus
2
. Medial dislocations are caused
by forceful inversion of the foot. The neck of the talus piv-
ots on the sustenaculum tali resulting in dislocation of the
talonavicular joint followed by dislocation of the subtalar
joint
3
. The patient presents with the foot plantarfl exed and
supinated in a position that has been described as ‘bas-
ketball foot’ after Graham reported four cases of medial
subtalar dislocations in young US military personnel who
sustained inversion injures playing basketball
4
.
In this instance the dislocation was overlooked by a jun-
ior emergency department (ED) doctor with limited expe-
rience in the assessment of musculoskeletal injures and
associated radiographic images. The complicating issue
with this patient was that on the contralateral side he had
a similarly ‘twisted foot’, which is why the junior doctor
considered this to be a benign foot and ankle sprain on the
involved side. In the busy environment of the ED it is easy
to rigidly adhere to the mantra that ‘common things are
common’ and resort to gestalt diagnosis. The mechanism
of injury and presentation was consistent with that of an
ankle sprain. However, the degree of bony deformity and
the radiographic images should have raised concern on the
part of the junior doctor. This case represents a ‘near miss’
of a signifi cant injury that could have had serious long-
term consequences for a young patient. It also illustrates
the importance of seeking senior help or specialty specifi c
guidance with unusual or atypical presentations or in cases
where uncertainty over clinical or investigative fi ndings
exists.
CASE PRESENTATION
A 24-year-old fi t and well male patient presented to the ED
late on friday night following a forced plantar fl exion and
inversion injury to the left foot while climbing out of his
car. He was fully compos mentis and non-weight bearing
on the affected side.
On examination the left foot was plantarfl exed and supi-
nated. There was no signifi cant swelling, ecchymosis or
neurovascular defi cit. Interestingly, he was noted to have a
very mild and easily correctible clubfoot deformity on the
right side. Inspection from the foot-end of the bed revealed
no difference in the position of affected and contralateral
limb. His medical and surgical history was unremarkable.
He was a smoker since the age of 14 and consumed 14–21
units of alcohol a week. There was no family history of
joint or connective tissue disorders.
INVESTIGATIONS
Antero-posterior and lateral radiographs of the foot and
ankle ( gures 1 and 2 ).
TREATMENT
Reduction under conscious sedation with midazolam and
morphine was attempted in the ED resuscitation bay. This
was unsuccessful and the patient was taken to operating
theatre for closed reduction under anaesthesia with prepa-
ration for open reduction and fi xation if required. Closed
reduction was successful and confi rmed with image intensi-
er radiography ( gure 3 ). The joint was found to be stable
and the patient furnished with a below knee non-weight
bearing cast and kept over night for neurovascular observa-
tions. He made an uneventful recovery and was discharged
home the next morning with a follow-up arranged in the
fracture clinic in 1 week with plain radiography ( gure 4 ).
OUTCOME AND FOLLOW-UP
The patient has made full recovery and returned to his pre-
injury functional status. He has been discharged from our
clinic.
Reminder of important clinical lesson
A near miss: an uncommon injury following a common
mechanism
David Bryson, Zeeshan Khan, Randeep Aujla, James David Bromage
Trauma and Orthopaedics Department, Kettering General Hospital, Kettering, Northamptonshire, UK
Correspondence to Dr David Bryson, davidjbryson@hotmail.com
Summary
Subtalar dislocation is an uncommon injury involving the simultaneous dislocation of the talocalcaneal and talonavicular joints. Radiographic
images can be diffi cult to interpret for the inexperienced clinician because of the obliquity of the foot and the overlap of tarsal bones. The
authors describe the case of a 24-year-old male who presented to the emergency department (ED) with a painful left foot and ankle following
a twisting injury. He was examined by a junior member of the ED team and diagnosed with a left ankle sprain. Preparations were underway
for discharge home when the radiographs, described as ‘normal but somewhat strange’, were shown to the orthopaedic senior house offi cer
who happened to be in the ED. The patient was subsequently reviewed by the orthopaedic registrar and diagnosed with a medial subtalar
dislocation. He was then taken to theatre for closed reduction and application of a below-knee cast.
BMJ Case Reports 2011; doi:10.1136/bcr.04.2011.4086
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DISCUSSION
Subtalar dislocation was fi rst described two centuries
ago in 1811 by Judcy and Dufaurents separately
5
. In
1964 Grantham reported fi ve cases of medial subtalar
dislocations sustained during athletic participation.
Forceful inversion was the mechanism of injury in each
case with four of the fi ve dislocations sustained while
playing basketball, prompting Grantham to describe the
injury as ‘basketball foot’
4
. In each case closed reduc-
tion and plaster immobilisation was employed to good
effect.
50–100% of subtalar dislocations are associated with a
fracture
6
, including fractures of the malleoli, osteochondral
fractures of the talonavicular or talocalcaneal joints and
base of the fi fth metatarsal
7
. Our patient did not have any
evidence of co-existing fractures of the foot and ankle or
osteochondral fractures. Prompt reduction, as with any
dislocation, is a tenet of initial management in order to
minimise further soft tissue and neurovascular injury
6
.
Closed reduction is successful in 80–90% of medial and
lateral dislocations
7
with minimal long-term disability seen
in those with uncomplicated dislocations who undergo
prompt management
5
. Potential complications of subtalar
dislocations include post-traumatic arthritis, osteonecrosis
and subtalar ankylosis
6
and are more likely to manifest
when there is a failure to diagnose and reduce the dislo-
cation promptly
5
. Fortunately for our patient, the risk of
such complications was minimised by the prompt actions
instituted by the orthopaedics on call team. However, had
the patient been discharged home, as was the original ED
management plan, the outcome could have been much
different.
Musculoskeletal conditions account for at least 10%
of consultations in general practice
8
and 20% of emer-
gency room attendances
9
. For many doctors, including
the ED senior house offi cer who fi rst examined this
patient, undergraduate teaching represents their only
exposure to orthopaedic surgery and musculoskeletal
medicine
9
. The situation is particularly challenging
in the time-pressured environment of the ED where
patients are managed by junior doctors with limited
clinical exposure to musculoskeletal disorders and asso-
ciated radiographic images. This is frequently com-
pounded by a lack of senior support during antisocial
hours. Until recently the ED in our own institution did
not have registrar cover between the hours of 2am and
Figure 2 Lateral radiograph demonstrating disruption of
talonavicular joint (red arrow).
Figure 1 Anterioposterior radiograph of left foot demonstrating
medial dislocation of the midfoot (highlighted by red arrow). This
is the radiograph that was described as ‘normal but somewhat
strange’.
BMJ Case Reports 2011; doi:10.1136/bcr.04.2011.4086
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8am. Consequently, junior trainees were left unsuper-
vised to manage all patients presenting to ED.
With an average duration of 5 weeks of orthopaedics
and trauma exposure at undergraduate level
8
, it would be
unreasonable to expect a junior trainee new to emergency
medicine to have a sound knowledge of the anatomy of the
subtalar joint and subtalar dislocations. As is the case with
all medical disciplines, there is no substitute for experience.
With repeated exposure to musculoskeletal ailments, cor-
relation of clinical and investigative fi ndings and a robust
system for radiographic assessment, near misses such as
the one described above may be kept to a minimum. In
cases where uncertainty persists, junior doctors should not
hesitate to seek senior or specialty specifi c input for assist-
ance and guidance.
Learning points
Be wary of making a diagnosis simply because it fi ts a
recognised pattern
Junior trainees should not hesitate to seek senior
guidance when there is uncertainty over clinical or
radiographic fi ndings
A consistent and robust system of radiographic
interpretation and correlation with clinical fi ndings is
required in order to reduce the risk of missing visible
fractures and uncommon injuries
Competing interests None.
Patient consent Obtained.
REFERENCES
1 . Heppenstall RB, Farahvar H, Balderston R, et al . Evaluation and management
of subtalar dislocations. J Trauma 1980 ; 20 : 494 – 7 .
2 . DeLee JC, Curtis R . Subtalar dislocation of the foot. J Bone Joint Surg Am
1982 ; 64 : 433 – 7 .
3 . Monson ST, Ryan JR . Subtalar dislocation. J Bone Joint Surg Am
1981 ; 63 : 1156 – 8 .
4 . Grantham SA . medical subtalar dislocation: fi ve cases with a common
etiology. J Trauma 1964 ; 4 : 845 – 9 .
5 . Hyder N, Jones S, Nair B . Medial subtalar dislocation . The Foot 1997 ; 7 : 34 – 6 .
6 . Jungbluth P, Wild M, Hakimi M, et al . Isolated subtalar dislocation. J Bone
Joint Surg Am 2010 ; 92 : 890 – 4 .
7 . Kinik H, Okty O, Arikan M, et al . Medial subtalar dislocation . Int Orthop
1999 ; 23 : 366 – 7 .
8 . Williams SC, Gulihar A, Dias JJ, et al . A new musculoskeletal curriculum:
has it made a difference? J Bone Joint Surg Br 2010 ; 92 : 7 – 11 .
9 . Freedman KB, Bernstein J . The adequacy of medical school education in
musculoskeletal medicine. J Bone Joint Surg Am 1998 ; 80 : 1421 – 7 .
Figure 3 Image intensifi er postreduction lateral view of patient
in s backslab showing well reduced talonavicular (A) and
talocalcaneal (B) joints.
Figure 4 Oblique view of the patient in plaster showing a well
reduced mid-foot: (A) talonavicular joint, (B) calcaneocuboid joint.
BMJ Case Reports 2011; doi:10.1136/bcr.04.2011.4086
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Bryson D, Khan Z, Aujla R, Bromage JD. A near miss: an uncommon injury following a common mechanism.
BMJ Case Reports 2011;10.1136/bcr.04.2011.4086, date of publication
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... To the best of our knowledge, only five cases of subtalar dislocation following to a low-energy mechanism are reported in 4 studies [16][17][18][19] ( Table 1). Jungbluth et al. [16] in a retrospective study from January 1994 to March 2007, reported the functional results of 23 patients with an isolated subtalar dislocation. ...
... At the final follow-up, good clinical and radiographic results were observed in both patients. Other authors [17][18][19] reported in three studies, isolated cases of medial subtalar dislocation that occurred after low energy trauma in three different patients. All these injuries were treated conservatively with good final results. ...
... All these injuries were treated conservatively with good final results. Brison et al. [17] reported a case of a 24-years old male caused by a forced plantar flexion and inversion injury while climbing out of his car treated by closed reduction and casting under anesthesia. The patient made full recovery and returned to his pre-injury functional status. ...
Article
Full-text available
Introduction Subtalar dislocation is a rare injury characterized by a simultaneous dislocation of the talocalcaneal and talonavicular joints. The most common type is caused by high-energy trauma with medial dislocation of the foot. This injury is frequently associated with fractures, but isolated dislocations are also reported. Case presentation We report a rare case of medial subtalar dislocation secondary to low-energy injury in a 61-year-old woman. Following X-rays and CT scan, prompt closed reduction was performed under sedation and, after reduction, X-rays showed a good realignment of the foot. The CT scan revealed an occult non-displaced fracture of the posterior part of the talus. The patient was managed conservatively by a non-weight bearing cast for four weeks, followed by a rehabilitation program. At follow-up, six months later, we observed a good clinical and radiographic result. Discussion The reported case confirms that the mechanism of injury is an important factor in predicting the final result, since subtalar dislocations secondary to a high-energy trauma are often associated with significant complications. We believe, in agreement with other authors, that a low-energy trauma generally doesn't produce long-term morbidity. Prompt reduction is very important in order to minimize soft tissue and neurovascular complications, although a CT is recommended to identify occult fractures. Conclusion Subtalar dislocations, caused by low energy trauma, if adequately reduced in the emergency room, generally heal with conservative treatment, reducing the risk of significant complications. However, since we report a single patient, further case analysis is needed to make solid conclusions.
... Furthermore, in the case of a high energy trauma, a subtalar joint dislocation (STJD) can occur, which consists of the displacement of two joints, namely, the talocalcaneal and the talonavicular. This rare condition represents <1%-2% of all large joint dislocations and approximately 15% of all talar injuries and was first described by DuFaurest and Judcy in 1811 [2,3]. Usually, this kind of injury affects young male patients [1] with a male-female ratio of about 3:1 [4]. ...
... In the literature, the medial STJD is described as a rare condition, representing <1%-2% of all foot dislocations [2,3]. Due to this fact, there is a lack of a gold standard conservative treatment; in the present study, outcomes with different types of conservative treatment and time of immobilisation were compared to highlight the best conservative treatment. ...
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In athletes, one of the most common injuries is a sprained ankle. If the energy of the trauma is particularly high, this type of injury can lead to an isolated medial dislocation of the subtalar joint (STJ), a rare condition poorly described in the literature. The aim of this study was to verify if a reliable conservative treatment and a specific physiotherapy rehabilitation protocol in isolated medial dislocation of the STJ in athletes is described in the literature. A systematic review of the published literature of the last 11 years was performed by applying the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines using three databases: Pubmed, Scopus, and Web of Science. The keywords used were "(subtalar OR talocalcaneal) AND dislocation". We considered only studies that included professional or amateur athletes (athletic patients). We used the American Orthopedic Foot and Ankle Society (AOFAS) scale, range of motion (ROM) of the subtalar and ankle joint, subtalar and talonavicular joint osteoarthritis, and patient feedback to evaluate their outcomes. A total of 12 studies were included in our review, with a total of 26 athletic patients. Sixteen of them had good results with the correlation between the duration of immobilisation and the outcomes. Nevertheless, due to the small number of patients included in the analysed studies on this subject in the literature, there is not yet a univocal clinical protocol to treat the isolated medial subtalar joint dislocation (STJD) warranting further research in the field.
... The medial subtalar joint dislocation is a rare injury, which accounts <1%-2% of all foot dislocations [7,8]. The most common cause is a fall from height [9]. ...
Article
Ankles injuries are common in sports such as football and soccer and one of the most serious and most rare is the subtalar dislocation. This injury is rare, touches young male patients and usually associated to fractures of the talus, the malleoli or the fifth metatarsal. Usually, this injury occurs in high-energy trauma, but it is very rare in sports injuries. Here we present the case of a 36-year-old male with an isolated Medial Subtalar Joint Dislocation after a severe tackle in a football (soccer) game. We performed a closed reduction under general anesthesia, and then a short-leg cast was applied for 4 weeks, followed by active and passive range of motion. At one-year follow up from trauma, the patient had a pain-free ankle with active full range of motion. For isolated medial subtalar dislocation occurring during sports activities, the first choice is the conservative treatment: Immediate closed reduction needs to be achieved followed by a short immobilization. Active/passive range of motion need to be started early to avoid joint stiffness.
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Background: The talonavicular joint is a rare site of dislocation. Its etiology varies and can be the result of either acute trauma or a chronic degenerative process that most commonly occurs in patients with rheumatoid arthritis or Charcot arthropathy. Our aim is to highlight the relationship between the underlying pathology of talonavicular dislocations and the final outcome in the case of operative management. Methods: We present three cases of talonavicular dislocation with the dislocation itself as the only common denominator, and a completely different etiology, natural history, treatment, and prognosis among them. Results: There was one case of a traumatic talocalcaneonavicular dislocation in a healthy individual, one case in a rheumatoid arthritis patient, and one case in a patient with diabetes mellitus. All patients were treated surgically. The outcomes were excellent, fair, and poor, respectively. Conclusions: Among many factors that influence prognosis, it is equally critical to evaluate the overall background in which the dislocation occurs so as to apply the suitable treatment. The surgeon not only needs to treat the local incident but also appreciate the general medical condition to provide the best final outcome to the patient.
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Twenty subtalar dislocations were reviewed in patients seen at the hospital complex of the University of Pennsylvania, 1950--1979. All patients were available for followup examination and roentgenographic review. These were 15 males and five females in the study. Length of followup ranged from 6 months to 23 years, mean, 4.2 years. Medial dislocation was most frequent, occurring in 17 out of 20. All three with lateral dislocations had associated fractures. All of the dislocations were closed injuries and only one patient required open reduction. Immobilization was maintained in a below-knee weight bearing cast for 6 weeks post-reudction. Of the patients, 80% demonstrated significant restriction of motion and 30% had roentgenographic evidence of arthritis. Few were symptomatic. Fourteen had excellent results, two good, two fair, and two poor. In general, a satisfactory result is to be expected with closed reduction following parenteral medication.
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A basic familiarity with musculoskeletal disorders is essential for all medical school graduates. The purpose of the current study was to test a group of recent medical school graduates on basic topics in musculoskeletal medicine in order to assess the adequacy of their preparation in this area. A basic-competency examination in musculoskeletal medicine was developed and validated. The examination was sent to all 157 chairpersons of orthopaedic residency programs in the United States, who were asked to rate each question for importance and to suggest a passing score. To assess the criterion validity, the examination was administered to eight chief residents in orthopaedic surgery. The study population comprised all eighty-five residents who were in their first postgraduate year at our institution; the examination was administered on their first day of residency. One hundred and twenty-four (81 per cent) of the 154 orthopaedic residency-program chairpersons who received the survey responded to it. The chairpersons rated twenty-four of the twenty-five questions as at least important. The mean passing score (and standard deviation) that they recommended for the assessment of basic competency was 73.1 +/- 6.8 per cent. The mean score for the eight orthopaedic chief residents was 98.5 +/- 1.07 per cent, and that for the eighty-five residents in their first postgraduate year was 59.6 +/- 12 per cent. Seventy (82 per cent) of the eighty-five residents failed to demonstrate basic competency on the examination according to the chairpersons' criterion. The residents who had taken an elective course in orthopaedic surgery in medical school scored higher on the examination (mean score, 68.4 per cent) than did those who had taken only a required course in orthopaedic surgery (mean score, 57.9 per cent) and those who had taken no rotation in orthopaedic surgery (mean score, 55.9 per cent) (p = 0.005 and p = 0.001, respectively). In summary, seventy (82 per cent) of eighty-five medical school graduates failed a valid musculoskeletal competency examination. We therefore believe that medical school preparation in musculoskeletal medicine is inadequate.
A near miss: an uncommon injury following a common mechanism, date of publication Become a Fellow of BMJ Case Reports today and you can: Submit as many cases as you like
  • D Bryson
  • Z Khan
  • R Aujla
  • Jd Bromage
Bryson D, Khan Z, Aujla R, Bromage JD. A near miss: an uncommon injury following a common mechanism. BMJ Case Reports 2011;10.1136/bcr.04.2011.4086, date of publication Become a Fellow of BMJ Case Reports today and you can: Submit as many cases as you like