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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 ( fi 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-
fi er radiography ( fi 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 ( fi 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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