Transchondral Fractures of the Talus on an lnversion Injury of the Ankle: A Frequently Overlooked Diagnosis

Transcription

1 /87/ $02.00/0 THE JOURNAL OF ORTHOPAEO~C AND SPORTS PHYSICAL THERAPY Copyright by The Orthopaedic and Sports Physical Therapy Sections of the American Physical Therapy Association Transchondral Fractures of the Talus on an lnversion Injury of the Ankle: A Frequently Overlooked Diagnosis R. H. M. HAGMEYER, PT,* P. VAN DER WURFF, PT Twenty-one cases of transchondral fractures of the ankle, seen between 1980 and 1984, were studied. Twenty were available for follow-up. The average follow-up period was 23.5 months. In all cases but one the diagnosis was delayed. The diagnosis stated by clinical signs in medial transchondral fractures seems to be pathognomic: localized tenderness on the posterior medial side of the talus, pain increasing on exertion, and provocation of pain on passive plantar flexion. Osteochondritis dissecans of the talus is defined as a subchondral bony lesion of a small fragment bone, usually under 2 cm in diameter.i3 In the opinion of A~hausen,~ it is an avascular process. Next to the vascular explanation for the etiology of osteochondritis dissecans, the theory of trauma has become increasingly p~pular.~,~ In opinion exists that there is spontaneous necrosis their classic paper in 1959, Berndt and Harty4 based on vascular phen~mena.~.~~.~~ The most suggested the term transchondral fracture of the important and accepted theory is that the lesion dome of the talus, defining it as "a fracture of the is caused by tra~ma.~~~~*~'' Berndt and Harty exarticular surface of bone produced by force trans- perimentally investigated the traumatic mechmitted from the articular surface of a contiguous anism of injury and produced some evidence in bone across the joint and through the articular support of their the~ry.~.~.'' cartilage to the subchondral trabeculae of the From this study, it appears that the following fractured bone." They believe that the inversion mechanisms, if carried out forcibly, can be reinjury is responsible for the existence of a trans- sponsible for the development of a medial transchondral fracture. Although the syndrome of chondral fracture. transchondral fractures has been described in sufficient detail in the clinical practice shows that the lesion is frequently overlooked. Physicians and physical therapists treating ankle injuries must consider the possibility of the existence of a transchondral fracture, because an overlooked transchondral fracture often causes many complaints in a delayed stage. Literature was reviewed and the experience of 21 patients is reported in this paper. The hereditary factor was favored by Wagoner and C~hn,~' St~ugaard,~' and Pick." A recent study of Petrie16 about this hereditary factor has shown that the common form of osteochondritis dissecans is not familiar. However, a body of Plantarflexion of the Ankle In the plantarflexion of the ankle, the narrow posterior half of the talar dome occupied the mortise somewhat loosely, owing to relaxation of the collateral ligament, and lateral rocking of the talus in the mortise was permitted. Etiology Many etiological factors have been postulated in the pathogenesis of transchondral fractures. ' Department of Physical Therapy. Military Rehabilitation Centre "Aardenburg." Driebergsestraatweg 1,3940 AD Doorn. The Netherlands. lnversion of the Ankle lnversion of the talus turned its medial border uppermost so that the articular surface of the tibia rested upon the ridge formed by the medial border of the talus. 362

2 JOSPT January 1987 TRANSCHONDRAL FRAC :TURES OF THE TALUS 363 Slight Anterior Displacement of the Tibia on the Talus Slight forward displacement of the tibia on the inverted talus then removed from contact with the talar border all of the tibia1 articular surface except the inferior posterior lip. Lateral Rotation of the Tibia on the Talus The impacting force was further increased by external rotation of the tibia on the talus. In their experiments, Berndt and Harty4 described that the development of the lateral transchondral fracture could be inflicted only by a strong inversion maneuver of the dorsiflexed ankle. In dorsiflexion, the talar bone is moved posteriorly into the mortise, impacting and compressing the lateral talar margin against the articular surface of the fibula, producing a small area of indention in the talar margin. Berndt and ~ arty~ classified the transchondral fractures in four stages (Fig. 1): stage I, compression of the subchondral trabeculae; stage II, a partially detached osteochondral fragment (Figs. I Stage I I Fig. 1. Transchondral fractures of the talus. 2 and 3): stage Ill, a completely detached osteochondral fragment, remaining in the crater; stage IV, a displaced osteochondral fragment. Symptomatology Transchondral fractures of the talus are seen in the acute and chronic phase of ankle distortion. In the acute phase, the dominant symptoms often caused by the initial inversion are: trauma, swelling, ecchymosis, limitation of motion or localized tenderness due to ligamentous injury. Berndt and Harty4 stated that there are no pathognomic symptoms associated with transchondral fractures. The duration of the acute phase is determined by the extent of the remaining lesions of the ligaments, the fracture size, and the degree of degeneration of the intra-articular cartilage surface. The symptoms in stages I, II, and Ill are those of osteoarthritis: stiffness, crepitation, pain, and swelling of the ankle during or after exertion. Besides those symptoms, we found that all our patients had an extremely tender spot localized on the talus, dorsal and posterior to the medial malleolus and painful passive plantarflexion. In addition to stage Ill, the symptoms of stage IV are also seen (due to the presence of the loose fragments) as instability and recurrent spraining. The radiological changes are usually found in the routine anteroposterior and lateral radiographs. An oblique projection in 10' of medial rotation opens up the talofibular joint and gives a clearer view of the lateral margins of the talus. In a case of expected medial lesion, the anteroposterior radiograph can be ensured in plantarflexion; lateral lesions in dorsiflexion. Tomography can be used in an effort to ensure optimal visualization of transchondral fractures stages I and 11.' PATIENTS AND METHODS In the period from December 1980 to December 1984, 21 patients were seen with ankle problems following an ankle distortion complicated by a transchondral fracture. In Table 1, an abstract of the information and the results of the follow-up study of the patients who were referred to our rehabilitation center is given. Two patients were female, 18 were male (N = 21) with a total number of 22 transchondral fractures. In 12 patients, the left leg was involved, and in 9 patients, the right leg. The youngest

3 364 HAGMEYER AND VAN DER WURFF JOSPT Vol. 8, No. 7 patient was 19 years old; the eldest, 61. The average age was 25.9 years. There were 19 medial, 1 lateral, and 1 lateral and medial transchondral lesions. All patients were referred to our center because of the persisting symptoms (Table 2). The previous therapy in all but 1 patient had been semiconservative: usually rest, pressure bandage, support stocking, and physiotherapy. One patient Fig. 2. Lateral transchondral fracture of the talus, stage 11. Rg. 3. Same lateral transchondr 91 fracture stage I1 on tomography. (No. 10) was treated conservatively (plaster cast) because the diagnosis transchondral fracture was made 2 weeks after the injury. The interval between the initial trauma and the diagnosis transchondral fracture varied from 2 weeks to 27 months with an average of 6.5 months. The diagnosis of transchondral fracture was expected on the basis of the history and clinical investigation and confirmed by tomography.

4 JOSPT January 1987 TRANSCHONDRAL FRACTURES OF THE TALUS 365 Case Sex Side Etiology Stage Lateral Lateral Inversion trauma Trauma Trauma. The distribution of the 22 transchondral fractures by stages (according to Berndt and Harty4) was: stage 1, 12; stage 11, 7; stage 111, 3; while stage IV was not seen. Eighteen patients had a history of inversion trauma; in 3 patients an accident was responsible for developing complaints. Table 2 gives a review of the symptoms at the time of admission in our rehabilitation center. Of the 21 patients, 4 required operative proce- TABLE 1 Summarv of case histories Duration symptoms 7 months 12 months 7 months 1.5 months 5 months 3 months 0.5 months 2 months 6 months 5 months 3 months 6 months 12 months 2 months 2 months 27 months 19 months Treatment Massage to decrease swelling Massage to decrease swelling Operation Plaster cast Massage Massage Massage Operation Operation Has to be operated Follow-up Complaints Limited movements Limited movements None Pain in rest and after exertion Limited movements Pain in rest and after exertion Locking ankle NO follow-up available No complaints Pain in rest and after exertion NO follow-up Results Good Good Good dures. One patient (No. 10) was cast as mentioned above. The remaining 16 patients were treated by means of mobilization, massage, and muscle exercises. All patients but one (No. 16) were available for follow-up investigation. The average follow-up period was 23.5 months. The results were as follows: 1 patient (No. 10) had no complaints at all. The remaining 15 patients all had complaints including crepitus, pain, and swelling during or after exertion.

5 366 HAGMEYER AND VAN DER WURFF JOSPT Vol. 8. No. 7 TABLE 2 Symptoms found during delayed clinical examination (n = 21) Tests Palpatory pain, localized on the talus, posterior of the medial rnalleolus Plantarflexion/inversion painful and limited Plantarflexion/inversion painful Plantarflexion/inversion limited Eversion painful and limited Muscle weakness Edema Instability Patients 20 times 11 times 8 times 1 time 1 time 3 times 3 times 2 times The results were rated by the following system; good, entirely or almost entirely free of symptoms; fair, complaints when tired or after prolonged exertion, sometimes swelling or instability of the ankle; poor, complaints at rest or after slight exertion, limitation of movement. The results of the 15 patients, treated by means of physiotherapy were: good-none, fair-8, and poor-7. DISCUSSION Both literat~re'~~~~~'~~'~~'~ and our investigations (Table 1) revealed that the diagnosis transchondral fracture should be considered with every ankle injury, especially those accompanied by a strong inversion moment. In the acute phase, the clinical picture of the transchondral fracture is usually dominated by damage of the lateral ligaments, which is an integral part of the injury. These symptoms make a good investigation almost impossible. Yet, if there is a clear abnormality in the anatomic stability, or history gives an impression of instability, stress radiographs should be taken into consideration. It is advisable to make routine radiographs of every inversion injury. On these radiographs, transchondral fractures stages Ill and IV are recognizable immediately, and an operation is indi- ~ated.'.~,~,'~ When stage Ill or IV is excluded, the treatment is semiconservative: rest, adhesive plaster strapping, and physiotherapy during the first 10 days. In this period, the symptoms of the initial sprain decrease and after 10 days a good clinical investigation is possible. Berndt and Harty4 have stated that there are no pathognomic signs associated with transchondral fractures. In our series, however, we found an extremely painful passive plantarflexion in 19 out of 20 patients having medial fractures. The pain was localized on the dorsomedial side of the ankle. At the same time, all patients showed localized tenderness to palpation in the dorsomedial border of the talar dome. The marks mentioned above proved to be a strong indication in the detection of a medial transchondral fracture stage I or II. When only cartilage is damaged, some "fractures" may not be seen initially; hence, radiographs should be repeated in subsequent studies. It is possible that only with the development of subchondral necrosis and bone resorption will radiographic evidence of pathology become apparent. One should consider or repeat radiographic investigation when the following symptoms are pre~ent:~ persistent complaints especially during or after exertion, a painful and/or limited plantarflexion, and a localized tenderness with digital palpation. If, in the acute phase, radiographic investigation proves positive for a transchondral fracture, stage I or II conservative treatment is indicated.'*~'~ According to most authors, this conservative therapy consists of a period of nonweightbearing combined with complete cast immobilization until the fracture appears united radiographically. Nonweightbearing is necessary to avoid the possibility that with continued friction, torsion, and compressive forces of even normal weightbearing stage I or stage II fractures may convert into stage Ill or stage IV type. Cast immobilization is necessary since, as with other fractures, the lesion may, on occasion, heal by ingrowth of capillaries from the parent bone.i5 The necessity to treat the ankle after cast immobilization by means of physiotherapy needs is inarguable. It is also possible that an inversion injury could be combined with a lateral transchondral fracture. In these cases, one could expect a painful passive dorsiflexion. Local tenderness is less reliable because of the position of the torn ligaments. During the time we reviewed transchondral fractures, we discovered a lateral transchondral fracture in only 2 patients, one combined with a medial transchondral fracture. The results of our study, as well as the consulting literature, show no sufficient treatment for the transchondral fracture stage I or stage II in the chronic phase. This information emphasizes the importance of early diagnosis to achieve optimal results. Early diagnosis of the lesion is mandatory, as a minimum of delay between diagnosis and therapy is important. The therapy in the

6 JOSPT January 1987 TRANSCHONDRAL FRACTURES OF THE TALUS 367 chronic phase of stages Ill and IV is always done operati~ely.',~-~< 14,24 CASE REPORTS Case 1 : Patient No. 6. A man, aged 23, suffered an inversion injury of the right ankle on May 24, There was swelling and tenderness over the lateral malleolus and he was treated as having a sprain. When seen in our center in September 1982, radiographs showed a medial dome fracture stage II according to Berndt and hart^.^ On examination, there was limited and painful plantarflexion and inversion. The pain was localized just dorsal to the medial malleolus. The treatment of this patient consisted of physiotherapy. No swelling or tenderness developed on this therapy with resultant subjective improvement. After a follow-up of 23 months he still complained of a severe pain after extensive use and stated that the leg "gave away" occasionally on walking. There was no swelling and the joint had a full range of movement. Case 2: Patient No. 10. A soldier, aged 21, sustained an inversion injury of the right ankle in a basketball game on November 12, There was swelling apd tenderness over the lateral malleolus and he was also treated as having a sprain. After 2 weeks, he was seen in our department. Examination showed pain over the medial side of the talus and passive plantarflexion was extremely painful. The symptoms on the lateral side were less. Tomography confirmed the diagnosis of medial transchondral fracture stage I. The patient was treated by means of a plaster cast for 6 weeks, and after this period of immobilization he received physical therapy. A follow-up period of 35 months revealed no complaints at all. REFERENCES 1. Alexander AH, Llchtman DM: Surgical treatment of transchondral talar-dome fractures psteochondritis dissecans). J Bone Joint Surg (Am) 62: Axhausen G: Die Unschreibenen Knorpelknockenlesionen des kniegelenks. Klin Wehnschr 56: , Axhausen F: Zum Vorkommen zes Abgrenzungsvorganges am Fussgelenk. Zentralbl Chir , Berndt AL and Harty M: Transchondral fractures (osteochondritis dissecans) of the talus. J Bone Joint Surg 41A: , Blom JHM, Strijk SP: Les~ons of the trochlea tali, osteochondral fractures and osteochondritis dissecans of the trochlea tali. Radiol Clin 44: , Brinkman WH, Fischer HJ, Jung H: Diagnose und therapy von talusfrakturen. Bruns' Beitr Klin Chir 220(2): Davidson AM: A review of twenty-one cases of transchondral fracture of the talus. J Trauma 7: De Ginder WL: Osteochondritis dissecans of the talus. Radiology , Franke K: Traumatologie des Sports, Ed 2. Berlin: VEB verlag, Goldstone RA, Pisani J: Osteochondritis dissecans of the talus. NY State J Med 10: , Hanly WL, McKasinck VA, Barranco FT: Osteochondritisdissecans with associated malformations in two brothers. J Bone Joint Surg (Am) 49: , Israeli A, Gamel A: Traumatic osteochondral lesions of the talus. Br J Sports Med 15: Kappis M: Weitere Beitrage zur Traumatisch Mechanischen Entstehung der "spontanen" Knorpelablosungen (sogen. osteochondritis dissecans). Deutsch Z Chir 171 :13-29, Mukherjee SK. Young A: Dome fracture of the talus. A report of ten cases. J Bone Jolnt Surg (Br) , O'Farrel TA. Costello BG: Osteochondritis dissecans of the talus. The late results of surgical treatment. J Bone Joint Surg (Br) 64: Petrie PWR: Aetiology of osteochondritis dissecans failure, to establish a familial background. J Bone Joint Surg (Br) 59: , Pick NP: Familial osteochondritis dissecans. J Bone Joint Surg (Br) 37: Sm~th GR, Winsquist R, Allan NK, Northrop CH: Subtle transchondral fractures of the talar dome, a radiological perspective. Radiology 124: Stougaard J: The hereditory factor in osteochondritis dissecans. J Bone Joint Surg (Br) 43: Stougaard J: Familial occurrence of osteochondritis dissecans. J Bone Joint Surg (Br) , Wagoner G, Cohn BNE: Osteochondritis dissecans. A resume of the theories of aetiology and consideration of heredity as an aetiological factor. Arch Surg 23:l-25, Watson-Jones R: Fractures and Joint Injuries, Ed 4. Baltimore: Williams 8 Wilkins Wiler P: Essentials of Orthopedics. Ed 2. Boston: Little Brown and Co, Yvars MF: Osteochondral fractures of the dome of the talus. Clin Orthop 114: