Broken Talus More Likely to Breat Again?
Human foot Fractures Oft Misdiagnosed as Talocrural joint Sprains
Am Fam Physician. 2002 Sep 1;66(5):785-795.
Article Sections
- Abstract
- Talar Dome Injuries
- Handling
- Lateral Procedure Fractures
- Posterior Process Fractures
- Fracture of the Anterior Process of the Calcaneus
- Last Comment
- References
Near ankle injuries are straightforward ligamentous injuries. However, the clinical presentation of subtle fractures can exist like to that of ankle sprains, and these fractures are ofttimes missed on initial test. Fractures of the talar dome may be medial or lateral, and they are unremarkably the event of inversion injuries, although medial injuries may be atraumatic. Lateral talar process fractures are characterized by betoken tenderness over the lateral procedure. Posterior talar process fractures are ofttimes associated with tenderness to deep palpation inductive to the Achilles tendon over the posterolateral talus, and plantar flexion may exacerbate the pain. These fractures can often be managed nonsurgically with nonweight-bearing status and a short leg bandage worn for approximately four weeks. Delays in treatment can issue in long-term disability and surgery. Computed tomographic scans or magnetic resonance imaging may exist required because these fractures are hard to detect on plainly films.
Ankle injuries are unremarkably evaluated by primary intendance and emergency physicians. Most of these injuries do non pose a diagnostic dilemma and can be managed nonsurgically without a prolonged or costly work-up. Even so, the clinical presentation of some subtle fractures tin can be similar to that of routine ankle sprains, and they are usually misdiagnosed every bit such. Many of these injuries, if left without a definitive diagnosis, outcome in long-term disability (Table 1).
Tabular array 1
Summary and Comparing of Presented Fractures
| Fracture blazon | Mechanism of injury | Important concrete examination findings* | Best apparently radiograph† | Treatment |
|---|---|---|---|---|
| Talar dome (lateral) | Inversion with dorsiflexion | Tenderness inductive to the lateral malleolus, along the anterior border of the talus | Mortise view: shallow, wafer-shaped lesion | Stage I or II (see Table 3): NWBSLC for 6 weeks Stage Three or 4 (see Table 3), or persistent symptoms: surgical Treatment |
| Talar dome (medial) | Inversion with plantar flexion or atraumatic | Tenderness posterior to the medial malleolus, forth the posterior border of the talus | AP view: deep, cup-shaped lesion; initial radiograph can exist normal because changes in subchondral bone may not develop for weeks. | Stage I, II, or III (come across Tabular array 3): NWBSLC for half dozen weeks Phase IV (see Table three): surgical treatment |
| Lateral talar process | Rapid inversion with dorsiflexion | Indicate tenderness over the lateral process (anterior and inferior to the lateral malleolus) | Mortise view; lateral view may show subtalar effusion | Pocket-size fragment with <2 mm Displacement: NWBSLC for four to 6 weeks Large or displaced fragments: operative treatment |
| Posterior talar Procedure (lateral tubercle) | Hyperplantar flexion or forced inversion | Tenderness to deep palpation anterior to the Achilles tendon over posterolateral talus Plantar flexion may reproduce pain. | Lateral radiograph (an accessory ossicle, the os trigonum, may be present) | Minimally displaced fracture: NWBSLC for four to vi weeks Large or displaced fragments or persistent symptoms: operative treatment |
| Posterior talar process (medial tubercle) | Dorsiflexion with pronation | Tenderness to deep palpation between the medial malleolus and the Achilles tendon | Difficult with standard views; an oblique ankle radiograph taken with the foot placed in 40 degrees of external rotation has been successful. | Similar to lateral tubercle Fractures |
| Inductive process of the calcaneus | Inversion with plantar flexion can lead to an avulsion fracture. Forced dorsiflexion compression fracture. | Point tenderness over the calcanealcuboid joint (approximately one cm inferior and iii to iv cm anterior to the lateral malleolus) | Lateral radiograph (an accessory ossicle, the calcaneus secondarium, may exist present) | Modest nondisplaced fracture: nonweight-bearing with compressive dressing or NWBSLC for four to six weeks Large or displaced fractures may require operative treatment. |
This article features subtle fractures to facilitate timely diagnosis and treatment of these less-common injuries. These fractures should be considered in the differential diagnosis of any acute talocrural joint sprain, too as any suspected sprain that does not ameliorate with routine treatment (Table ii).
Tabular array 2
Mutual Management of Talocrural joint Sprains
| Acute care | Articulation residuum, ice, compression, and height (RICE) |
| Simple analgesics for 24 to 72 hours | |
| Follow-upward care | Progressive range-of-move and proprioceptive exercises |
| Protection from further ankle injury with a wrap or brace | |
| Gradual return to normal activity level |
Overall, optimal results are achieved with early on diagnosis and handling of these fractures. When treatment is delayed, patients tend to have a more than complex clinical form.
Talar Dome Injuries
- Abstruse
- Talar Dome Injuries
- TREATMENT
- Lateral Process Fractures
- Posterior Process Fractures
- Fracture of the Anterior Process of the Calcaneus
- Final Comment
- References
The dome of the talus articulates with the tibia and fibula, and has a key office in ankle motion and in supporting the centric load during weight bearing1–4(Figures one and 2). Fractures of the talar dome are generally the upshot of inversion injuries of the ankle. They are located medially or laterally with equal frequency and occasionally through both.3–5 Lateral talar dome fractures are almost always associated with trauma, while medial talar dome lesions tin can be traumatic or atraumatic in origin.
Figure 1.
Bones of the foot, dorsal view.
Effigy 2.
Basic of the foot and talocrural joint, lateral view.
Although the etiology in atraumatic lesions is unclear, osteochondral fragments tin can dissever from the surrounding cartilage surface and dissect into the joint space. Equally these osteochondral fragments (often referred to as osteochondritis dissecans lesions) become loose in the joint, they tin crusade pain, locking, crepitance, and swelling.1,four,5
DIAGNOSIS
Clinical diagnosis of talar dome fractures tin can be highly challenging because there are no pathognomonic signs or symptoms.5 The patient may have sustained a autumn or a twisting injury to the talocrural joint and may mostly ambulate with an antalgic gait. In the acute setting, the symptoms of a talar dome fracture are similar to and often occur with an talocrural joint sprain.three,5
In lateral talar dome lesions, tenderness is generally found anterior to the lateral malle-oli, along the anterior lateral border of the talus.3,6 In medial talar dome lesions, tenderness is usually located posterior to the medial malleolus, forth the posterior medial border of the talar dome.3,vi Chronic talar dome lesions—traumatic and atraumatic osteo-chondritis dissecans lesions—may accept a clinical presentation similar to that of arthritis. Typical findings include crepitance, stiffness, and recurrent swelling with action.5
Diagnosis of talar dome lesions can oft exist fabricated with standard anteroposterior (AP), lateral, and mortise ankle radiographs. However, repeated radiographs may exist necessary considering initial films may appear normal. Secondary changes in the subchondral bone (visible on evidently radiographs) caused by a compression fracture of the articular osteochondral surface may accept weeks to announced.two,4 In addition, small chondral fragments are radiolucent and non axiomatic on standard radiographs.
Generally, the AP ankle view is all-time for visualizing deep, cup-shaped medial lesions,ane,4 although the lesions are often appreciated on the mortise view besides (Figure 3). Lateral lesions are all-time visualized on a mortise view and are more often than not thin and wafer-shaped.i,iv(Figure iv). If suggested by the clinical scenario, fractures non visualized with plain radiographs may require magnetic resonance imaging (MRI) or computed tomography (CT).half-dozen The fracture classification developed by Berndt and Harty is widely used to stage talar dome lesions (Table 3).v
Effigy 3.
Mortise view of the ankle showing an atraumatic osteochondral lesion (arrow) of the medial talar dome.
Figure 4.
Mortise view (left) and anteroposterior view (right) of the ankle showing a traumatic lateral talar dome fracture (arrows).
TABLE three
Berndt and Harty Classification of Osteochondral Lesions of the Talar Dome
| Phase I | Compression fracture of subchondral os |
| Stage II | Fractional osteochondral fragment fracture |
| Stage III | Completely detached fragment without deportation |
| Stage Iv | Completely detached fragment with displacement |
TREATMENT
- Abstract
- Talar Dome Injuries
- Handling
- Lateral Process Fractures
- Posterior Process Fractures
- Fracture of the Anterior Process of the Calcaneus
- Final Comment
- References
An orthopedic surgeon should exist consulted for handling of talar dome lesions because of the loftier functional demands of for the talar dome and the potential for complications. Phase I, Ii, and Iii medial lesions tin can usually be treated nonsurgically with six weeks in a nonweight-bearing cast.1,3,5 Adequate reduction and immobilization are crucial for fracture healing and to avert avascular necrosis of the fracture fragment.five
Patients with stage III lateral lesions, stage IV lesions, and persistent symptoms are by and large treated surgically. Treatment options fragment excision range from arthroscopy with or without subchondral bone drilling to open reduction internal fixation.iv,5
Lateral Process Fractures
- Abstract
- Talar Dome Injuries
- TREATMENT
- Lateral Procedure Fractures
- Posterior Process Fractures
- Fracture of the Anterior Process of the Calcaneus
- Final Comment
- References
The lateral talar process is an osseous protuberance that articulates superolaterally with the fibula, helping to stabilize the talocrural joint mortise, and inferomedially with the calcaneus, forming the lateral portion of the subtalar joint7(Figures 1 and ii). Lateral process fractures are the 2nd most mutual talar fractures. From 33 to 41 pct of these fractures are missed on initial presentation.8–11 Traditionally, the causative injuries are falls, motor vehicle crashes, or straight trauma. Some recent reports7–ix,12 implicate snowboarding accidents in these fractures.
DIAGNOSIS
The patient commonly has a history of a rapid inversion and dorsiflexion injury.7–9 Fractures of the lateral process range from avulsion fractures of the capsular ligaments to intra-articular injuries involving the ankle and subtalar joints.nine
Physical test findings are similar to those in lateral ankle ligamentous injuries. Pain with plantar flexion, dorsiflexion, and subtalar joint movement is generally present.7 Although the normal anatomy of the talocrural joint may be obscured by soft tissue swelling, a helpful diagnostic indicator is point tenderness over the lateral procedure. The lateral process tin be palpated anteriorly and inferiorly to the tip of the lateral malleolus.viii,11
Fractures can usually exist visualized on a standard ankle series9(Figure 5). A posterior subtalar effusion seen on the lateral view is highly suggestive of an occult lateral process fracture.13 A CT browse tin clearly show this injury and may be required to confirm a suspected fracture.11
FIGURE 5.
Anteroposterior view of the talocrural joint showing a fracture (arrow) of the lateral process of the talus.
Treatment
A nonweight-bearing, brusque leg cast can be used if anatomic position with less than 2 mm deportation tin can be maintained.7,xi A nonweight-begetting bandage should be maintained for four to six weeks, followed past ii weeks in a walking cast and initiation of rehabilitation exercises.seven For large and displaced fragments, the treatment of option is commonly surgical reduction and fixation.7,8
Posterior Process Fractures
- Abstract
- Talar Dome Injuries
- Treatment
- Lateral Process Fractures
- Posterior Procedure Fractures
- Fracture of the Anterior Process of the Calcaneus
- Final Annotate
- References
The posterior process of the talus is composed of two tubercles, the lateral and medial (Figures one and 2). The lateral tubercle is the larger of the two and serves as the attachment of the posterior talocalcaneal and posterior talofibular ligaments.9,fourteen,xv The medial tubercle serves every bit the zipper for the posterior tertiary of the deltoid ligament.ix,14,xv The under-surface of both tubercles forms the posterior fourth of the subtalar joint.9,xiv
An accessory bone known as the ostrigonum is relatively common, posterior to the lateral tubercle.six,15 The bone trigonum tin be a source of pathology, and a normal os trigonum may be confused with a fracture of the lateral tubercle.2,ix,14
Again, these fractures take been commonly misdiagnosed as ankle sprains.ii,9,15,sixteen One time serial,15 17 of 20 patients with fractures were misdiagnosed with ankle sprains. Posterior process fractures can occur at either or both tubercles.xiv–18 Lateral and medial tubercle fractures are discussed separately.
FRACTURES OF THE POSTERIOR PROCESS: LATERAL TUBERCLE
Fractures of the lateral tubercle tin exist caused by hyperplantar flexion or inversion.ane,2,15 Hyperplantar flexion injuries tend to cause pinch fractures, while inversion injuries tend to produce avulsion fractures.1,two,fifteen Both of these injuries take been described after falls and accept been associated with football and rugby boot injuries, which place the ankle in a forced plantar flexed position.19 If nowadays, an bone trigonum tin be injured past the same mechanisms described above.two,19
Diagnosis
Clinically, patients with a fracture of the lateral tubercle present with hurting and swelling in the posterolateral area of the ankle. The pain is often exacerbated past activities requiring plantar flexion.15 Physical examination findings in lateral tubercle fractures of the posterior process are highly consequent for tenderness to deep palpation inductive to the Achilles tendon over the posterior talus. The pain is often reproduced with plantar flexion and occasionally accentuated with dorsiflexion of the great toe. This is caused past compression of the fracture fragment as the flexor hallucis longus tendon passes between the medial and lateral tubercle.15
Careful concrete examination and correlation with radiographic findings may be necessary to differentiate a fracture of the lateral tubercle, a fracture of a fused os trigonum, a tear in the fibrous attachment of the ostrigonum to the lateral tubercle, or a normal os trigonum.2,6,nineteen
A lateral radiograph of the pes usually best visualizes the lateral tubercle and, if nowadays, the os trigonum.6,9 When evaluating the fracture line, a rough, irregular cortical surface suggests the presence of an acute fracture (Effigy 6). In astute injuries, this rough irregular surface may help distinguish a fracture from a normal os trigonum, which generally has a smooth, rounded cortical surface.xv In chronic cases, these differences may be less distinct, making the stardom between a fracture and a normal bone trigonum difficult. When the diagnosis is unclear and clinical suspicion is nowadays, an MRI or CT will conspicuously demonstrate this fracture.xvi
Figure 6.
Lateral view of the ankle showing a fracture of the lateral tubercle of the posterior process of the talus. The faint vertical lucency (arrow) is the fracture line.
Treatment
Nondisplaced or minimally displaced fractures can be treated with a not-weight-bearing, short leg bandage for four to vi weeks.nine,15 After this menses of immobilization, weight begetting is immune every bit tolerated. If symptoms persist, an additional iv to six weeks of immobilization would exist recommended.6 If the fracture site continues to be symptomatic after 6 months, fragment excision is usually curative.6,ix Larger and more displaced fractures may crave open reduction internal fixation.6,16
FRACTURES OF THE POSTERIOR Process: MEDIAL TUBERCLE
Medial tubercle fractures are relatively rare.17,18 They were starting time described by Cedell,18 who presented four cases of medial tubercle fractures that had originally been treated as talocrural joint sprains.
Diagnosis
More often than not, medial tubercle fractures are secondary to dorsiflexion, pronationtype injuries, because the medial tubercle is avulsed by the deltoid ligament.17,xviii
On clinical assessment, there may be only slight pain with airing and range-of-motion testing.half-dozen,18 Patients with medial tubercle fractures typically have swelling and pain posterior to the medial malleolus and anterior to the Achilles tendon.17,eighteen,20
Visualization of the medial tubercle fracture on plain radiograph may be challenging, but the fracture can more often than not be seen on an oblique projection with the human foot and talocrural joint externally rotated forty degrees and the beam centered 1 cm posterior and inferior to the medial malleolus16,17(Effigy 7). Yet, CT (Effigy viii) or MRI may exist necessary if the diagnosis is unclear.xvi,17
FIGURE seven.
Special oblique view of the ankle showing a medial tubercle fracture (arrow) of the posterior process of the talus.
Figure 8.
Computed tomographic scan demonstrating a medial tubercle fracture (arrow) of the posterior process of the talus.
Treatment
Medial tubercle fractures are treated in a manner similar to that for lateral tubercle fractures.17,18,20
Fracture of the Anterior Process of the Calcaneus
- Abstract
- Talar Dome Injuries
- Handling
- Lateral Process Fractures
- Posterior Process Fractures
- Fracture of the Anterior Process of the Calcaneus
- Final Comment
- References
The anterior process of the calcaneus is a saddle-shaped bony protuberance that articulates with the cuboid. It is attached to the cuboid past an interosseous ligament and to the cuboid and navicular bones past the stiff bifurcate ligament21,22(Figures 1 and 2). Fractures of the anterior procedure business relationship for approximately fifteen per centum of all calcaneal fractures and are commonly misdiagnosed as ankle sprains.half-dozen,21,23,24
Inductive process fractures issue from avulsion or compression. Inversion plantar flexion can cause avulsion fractures of the anterior procedure. This injury tends to exist extra-articular and accounts for most of the inductive process fractures that are initially diagnosed every bit talocrural joint sprains.21–23
Anterior process fractures secondary to pinch generally occur when the foot is forcefully dorsiflexed and the anterior process is pressed against the cuboid.22 Because of the energy involved with this mechanism, inductive process fractures secondary to compression are often intra-articular and are usually associated with other fractures.vii,23
DIAGNOSIS
Patients with anterior process fractures generally have a history of a previous inversion injury or involvement in a motor vehicle crash.21 Clinically, patients generally show signs and symptoms similar to those of a lateral ankle sprain.21,23 The pain may be minimal with standing but increases substantially with airing.21,23 An important diagnostic characteristic is signal tenderness over the calca-neocuboid joint that is localized approximately ane cm inferior and 3 to 4 cm anterior to the lateral malleolus, only distal to the anterior talofibular ligament insertion.21,22,23 Careful assessment of the betoken of maximal tenderness may help differentiate this fracture from a lateral ligament sprain.21,23
Although this fracture can be hard to appraise on routine radiographs of the pes and ankle, a careful inspection of the lateral view of the calcaneus often reveals this subtle fracture21,24(Figure nine). As the clinical scenario dictates, a CT scan or MRI may be necessary.9,21,23 In add-on, an accessory ossicle (calcaneus secondarium) maybe located near the anterior procedure and could be misinterpreted every bit a fracture.21,24
Figure 9.
Lateral view of the foot and talocrural joint showing a fracture (arrow) of the anterior process of the calcaneus.
TREATMENT
For small, nondisplaced fractures, early on immobilization in a nonweight-begetting, short leg cast or compressive dressing for four to six weeks followed by range-of-move exercises and a gradual return to weight begetting has been successful.21,23
Although fracture healing may appear radiographically to be complete, approximately 25 percent of patients require more than a yr before becoming asymptomatic.21 Post-obit nonsurgical management, most patients report satisfactory results and a return to preinjury activity levels.21,23,24 Symptomatic nonunions or big, displaced fractures may crave surgical intervention.21,24
Final Comment
- Abstract
- Talar Dome Injuries
- TREATMENT
- Lateral Process Fractures
- Posterior Process Fractures
- Fracture of the Anterior Process of the Calcaneus
- Final Comment
- References
The fractures discussed here can be serious injuries and cause prolonged disability. In general, extra-articular fractures of the talus and calcaneus can exist managed with nonsurgical handling. However, intra-articular fractures crave special attention to ensure that the articular surface is restored to anatomic congruity and that the correct mechanical alignment is maintained. This pace optimizes the gamble for a full recovery and decreases the incidence of post-traumatic arthritis and associated morbidities.
Appropriate radiographs are essential to the diagnosis of these fractures but, in the piece of work-up of an ankle injury, radiographs are not ever required. The Ottawa ankle rules (Effigy ten 25) offering the physician clinical guidance as to which injuries require radiographs. Prospective studies accept validated the effectiveness of these guidelines and shown the rules to be 100 percent sensitive for clinically significant fractures.25,26
FIGURE 10.
Adaptation of the Ottawa ankle rules used to determine when to obtain radiographs of the human foot or ankle in patients with acute ankle injury. An ankle radiographic series is only required if there is pain in the malleolar zone and any of the following findings are present: bone tenderness at bespeak A or B, or inability to bear weight immediately following the injury and during examination. A pes radiographic series is merely required if there is pain in the midfoot zone and any of the post-obit findings are present: os tenderness at indicate C or D, or inability to comport weight immediately following the injury and during examination.
Adapted with permission from Rubin A, Sallis R. Evaluation and diagnosis of talocrural joint injuries. Am Fam Physician 1996;54:1609–18.
Although fractures of the talus were vary rarely encountered in the Ottawa ankle trials, the fractures discussed in this article would likely be identified using the Ottawa ankle rules, considering of the inability of the patient to comport weight later the injury and during the test.
Nevertheless, some patients with these fractures are able to ambulate and, considering patients with these fractures generally practise not nowadays with tenderness along the posterior border of the lateral or medial malleolus, radiographic evaluation may not be indicated under the Ottawa guidelines. However, as with all guidelines, clinical judgment and experience may be grounds for radiographic assay in unique cases. Furthermore, in the instance of a suspected ankle sprain that does not ameliorate as expected or is accompanied by tenderness over a potential fracture site, radiographic analysis at a follow-upward evaluation may be indicated. The fracture may then be diagnosed and treated soon enough later on the injury to avert an adverse prognosis.
To run into the total article, log in or buy access.
REFERENCES
show all references
ane. Higgins TF, Baumgaertner MR. Diagnosis and treatment of fractures of the talus: a comprehensive review of the literature. Foot Talocrural joint Int. 1999;20:595–605. ...
2. Keene JS, Lange RH. Diagnostic dilemmas in foot and ankle injuries. JAMA. 1986;256:247–51.
3. Nash WC, Baker CL Jr. Transchondral talar dome fractures: not just a sprained ankle. South Med J. 1984;77:560–4.
4. Canale ST, Belding RH. Osteochondral lesions of the talus. J Os Articulation Surg [Am]. 1980;62:97–102.
five. Berndt AL, Harty Thou. Transchondral fractures(osteochondritis dissecans) of the talus. J Bone Joint Surg [Am]. 1959;41:988–1020.
6. DeLee JC. Fractures and dislocations of the pes. In: Mann RA, Coughlin MJ, eds. Surgery of the foot and ankle. sixth ed. St. Louis: Mosby, 1993:1465–1703.
7. Hawkins LG. Fracture of the lateral procedure of the talus. J Bone Joint Surg. 1965;47:1170–five.
viii. Mukherjee SK, Pringle RM, Baxter Advertizement. Fracture of the lateral process of the talus. A study of thirteen cases. J Bone Joint Surg [Br]. 1974;56:263–73.
9. Heckman JD. Fractures and dislocations of the foot. In: Rockwood CA, Green DP. Rockwood and Green'south Fractures in adults. quaternary ed. Philadelphia: Lippincott-Raven, 1996:2313–16.
ten. Heckman JD, McLean MR. Fractures of the lateral process of the talus. Clin Orthop. 1985;199:108–13.
11. Tucker DJ, Feder JM, Boylan JP. Fractures of the lateral procedure of the talus: ii case reports and a comprehensive literature review. Foot Ankle Int. 1988;19:641–vi.
12. Kirkpatrick DP, Hunter RE, Janes PC, Mastrangelo J, Nicholas RA. The snowboarder'south foot and talocrural joint. Am J Sports Med. 1998;26:271–7.
13. Cimmino CV. Fracture of the lateral process of the talus. Am J Roentgenol. 1963;90:1277–80.
14. Nasser S, Manoli A 2d. Fracture of the unabridged posterior process of the talus: a case report. Foot Ankle. 1990;10:235–8.
fifteen. Paulos LE, Johnson CL, Noyes FR. Posterior compartment fractures of the ankle. A commonly missed able-bodied injury. Am J Sports Med. 1983;11:439–43.
16. Kim DH, Hrutkay JM, Samson MM. Fracture of the medial tubercle of the posterior process of the talus: a case report and literature review. Foot Ankle Int. 1996;17:186–8.
17. Nadim Y, Tosic A, Ebraheim N. Open reduction and internal fixation of fracture of the posterior process of the talus: a case report and review of the literature. Foot Ankle Int. 1999;xx:l–ii.
18. Cedell CA. Rupture of the posterior talotibial ligament with the avulsion of a bone fragment from the talus. Acta Orthop Scand. 1974;45:454–61.
xix. McDougall A. The os trigonum. J Bone Joint Surg [Br]. 1955;37:257–65.
20. Stefko RM, Lauerman WC, Heckman JD. Tarsaltunnel syndrome caused by an unrecognized fracture of the posterior process of the talus (Cedell fracture). A case report. J Bone Joint Surg [Am]. 1994;76:116–eight.
21. Degan TJ, Morrey BF, Braun DP. Surgical excision for inductive-process fractures of the calcaneus. J Bone Joint Surg [Am]. 1982;64:519–24.
22. Jahss MH, Kay BS. An anatomic study of the inductive superior process of the os calcis and its clinical application. Foot Ankle. 1983;3:268–81.
23. Bradford CH, Larsen I. Sprain-fractures of the inductive lip of the bone calcis. N Engl J Med. 1951;244:970–2.
24. Hodge JC. Inductive procedure fracture or calcaneus secundarius: a case report. J Emerg Med. 1999;17:305–9.
25. Rubin A, Sallis R. Evaluation and diagnosis of talocrural joint injuries. Am Fam Physician. 1996;54:1609–xviii.
26. Stiell IG, Greenberg GH, McKnight RD, Nair RC, McDowell I, Reardon Chiliad, et al. Conclusion rules for the employ of radiography in acute talocrural joint injuries. Refinement and prospective validation. JAMA. 1993;269:1127–32.
Copyright © 2002 by the American Academy of Family Physicians.
This content is endemic by the AAFP. A person viewing information technology online may make 1 printout of the material and may utilize that printout only for his or her personal, not-commercial reference. This cloth may not otherwise be downloaded, copied, printed, stored, transmitted or reproduced in any medium, whether now known or later invented, except every bit authorized in writing by the AAFP. Contact afpserv@aafp.org for copyright questions and/or permission requests.
Near RECENT Result
Mar 2022
Access the latest issue of American Family Physician
Read the Outcome
Email Alerts
Don't miss a unmarried event. Sign upwardly for the gratis AFP e-mail table of contents.
Sign Up Now
Source: https://www.aafp.org/afp/2002/0901/p785.html
Belum ada Komentar untuk "Broken Talus More Likely to Breat Again?"
Posting Komentar