SLR - February 2021 - Duan Zhang

Systematic Review: Diagnostics, Management and Outcome of Fractures of the Posterior Process of the Talus

Reference:Engelmann EWM, Wijers O, Posthuma JJ, Schepers T. Systematic Review: Diagnostics, Management and Outcome of Fractures of the Posterior Process of the Talus. Injury. 2020;51(11):2414-2420.

Level of Evidence: IV

Scientific Literature Review

Reviewed By: Duan Zhang, DPM
Residency Program: NYU Langone Hospital Centers – New York, NY

Podiatric Relevance: Fractures to the posterior aspect of the talus are rare, however when missed it could be devastating for the patient causing arthritis and chronic pain in the future. This article looks at previous papers on fractures to the posterior process of the talus and provides a systematic review to reach a conclusion on recommendations for the diagnosis, management, and outcome of such fractures. 

Methods: Electronic databases were searched in January 2020 to identify all studies on posterior process fractures of the talus. Exclusion criteria included chiropractic journals, cases series less than three patients, cadaver studies, and reviews. The variables noted for analysis were year of publication, type of study, number of patients, gender, age, mechanism of injury, type of fracture, imaging modality, treatment, postoperative protocol, primary outcomes, complications and duration of follow-up.

Results: Seven retrospective cases series met the criteria for analysis. A total of 66 patients were included, 58.9 percent were male and 41.15 percent were female. The mechanisms of injury included: fall from height, motor vehicle accidents, fall during daily activities, sports injuries, and direct trauma. 37.9 percent of patients presented with a subtalar joint dislocation and 51.5 percent of patients had ipsilateral lower extremity fractures. Except for the oldest study, all the patients had x-rays and CTs performed. Delayed diagnosis or missed fractures were found in 36.4% of all patients. In the 24 cases with delayed diagnosis, treatment was fragment excision (54.2 percent), nonoperatively (41.7 percent) and one patient with ORIF. In the 42 patients who were diagnosed immediately after trauma, the majority was managed operatively with ORIF (70.5 percent) or primary arthrodesis compared to nine patients treated non-operatively (21.4 percent). Functional outcome data was available for 48 patients, where 20 reported impaired function (41.7 percent) of which 70 percent were patients with delayed diagnosis. One third of the patients developed complications. The most common complication was chronic pain, followed by symptomatic osteoarthritis and STJ fusion. More complications were found in the non-operative group (73.7 percent) compared to the ORIF group (26.3 percent). 

Conclusions: Fractures of the posterior process of the talus is often associated with subtalar joint dislocation and factures to other parts of the lower extremity. CT is the recommended imaging to view these fractures, but the high rate of delayed diagnosis shows that this can be difficult to diagnosis and treat in a timely fashion. Most patients who were diagnosed immediately after trauma underwent ORIF, and more than 2/3 of these patients returned to daily activities without complaints. A significantly higher rate of impaired function or complications was found in the non-operative group compared to the operative group. ORIF is recommended when there is displacement, articular involvement or if the fracture extends into the body of the talus. Alternatively, fragment excision may be indicated for smaller, impinging fragments and in case of previously missed fractures, while non-operative treatment is reserved for non-displaced fractures only.

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