Pertinent Pearls On Surgical Management Of A Displaced Sustentaculum Tali Fracture

This author describes open reduction and internal fixation of an isolated sustentaculum tali fracture in a 24-year-old female.

Fracture of the sustentaculum tali (Rowe type 1b) is rare and due to the strong ligament attachments of the medial subtalar joint, the fracture fragment often does not displace. However, in cases where there is displacement, open reduction and internal fixation (ORIF) is indicated.¹

A 24-year-old female got a referral from the emergency department and presented to my office for the treatment and evaluation of a foot injury. She fell from a height while rock climbing and landed with her foot in a supinated position. Radiographs taken in the emergency department raised suspicions for a calcaneal fracture. I placed her in a posterior mold splint and she subsequently used crutches to remain non-weightbearing.

I performed a comprehensive history and physical exam in the office. The clinical exam revealed swelling and ecchymosis along the medial aspect of her hindfoot. Her skin was intact and neuromuscular status was intact with no signs or symptoms of compartment syndrome.

She had radiographs taken in the emergency department and they consisted of lateral, anteroposterior and medial oblique views. An additional radiograph view (calcaneal axial) in the office revealed a fracture of the sustentaculum tali. I ordered a computed tomography (CT) scan to further evaluate the fracture pattern and rule out additional fractures. The scan revealed an isolated, displaced fracture (greater than 2 mm) of the sustentaculum tali (Rowe type 1b). Displacement of the sustentaculum tali produces a varus position of the hindfoot. Leaving this as is will result in poor outcomes. 

I counseled the patient on the treatment options, which included a recommendation for surgery. After careful consideration, I scheduled her for surgical management. She was immobile in a well-padded compressive dressing with a posterior mold splint to allow her soft tissue to normalize and was non-weightbearing with crutches. When the swelling resolved and skin lines returned, I performed ORIF. 

Key Pearls On Performing ORIF

After ensuring supine positioning of the patient, I applied a well-padded tourniquet and prepped and draped her foot, ankle and lower leg in the usual fashion. I inflated the tourniquet and directed my attention to the medial aspect of her hindfoot. With the use of fluoroscopy, I used an 18-gauge needle to help locate the sustentaculum tali. I also employed lateral and calcaneal axial views. This approach allows the surgeon to place the incision directly over the sustentaculum tali, thereby avoiding unnecessary dissection.

Place an incision directly over the sustentaculum tali and perform careful dissection. I use this same technique for the approach to a resection of a middle facet coalition. Carry meticulous dissection down through the subcutaneous tissue layers. Identify the posterior tibial and flexor digitorum longus tendons, and safely retract them dorsally. After obtaining direct visualization of the sustentaculum tali, I plantarly displaced the intra-articular fracture, which involved the middle facet. I proceeded to reduce the cortical surface and restore the height.

Due to the bone’s many ligamentous attachments, it was difficult to manipulate the small piece of bone. Instead, I manipulated the calcaneal tuber, pulling it down and reducing from its varus position. This technique adequately restored the joint surfaces.

Employing provisional fixation for the fracture, I placed two guide wires from medial to lateral into the sustentaculum tali, angling the wires were slightly plantar and proximal. Fluoroscopy confirmed the reduction and wire placement. I proceeded to place two 4.0 mm partial threaded screws over their respective guide wires. This resulted in excellent compression occurred as the use of two screws resisted rotational forces. Buttress plating is also a fixation option for these fractures but requires additional dissection. I again used fluoroscopic views (lateral and calcaneal axial) to confirm reduction and screw placement.

At this point, one can deflate the tourniquet and achieve hemostasis. Copiously irrigate the wound and close it in layers. I then placed the patient in a well-padded compressive dressing with a posterior mold splint. She went home the same day and got instructions to remain non-weightbearing. 

The patient was non-weightbearing in the splint for two weeks. After healing of the incision and suture removal, the patient wore a removable boot to allow range of motion of her ankle while maintaining non-weighbearing status. Six weeks after surgery, radiographic healing was evident and she began to transition to weightbearing in the boot. Two weeks later (eight weeks from surgery), she began wearing a supportive sneaker and initiated formal physical therapy to focus on strength training and range of motion of her ankle and hindfoot. By three months, the patient had returned to full activities without complaints.

In Summary

Isolated fractures of the sustentaculum tali are not very common (1 percent of calcaneal fractures), and due to the strong ligament attachments of the medial subtalar joint, the fracture often does not displace.2 However, when there is displacement, this intra-articular fracture requires anatomic reduction and fixation for optimal outcomes.

Dr. Bevilacqua is a board-certified, fellowship-trained foot and ankle surgeon with North Jersey Orthopaedic Specialists in Teaneck, NJ.

References

1. DellaRocca GJ, Nork SE, Barei DP, et al. Fractures of the sustentaculum tali injury characteristics and surgical technique for reduction. Foot Ankle Int. 2009;30(11):1037-1041
2. Durr C, Zwipp H, Rammelt S. Fractures of the sustentaculum tali. Oper Orthop Traumatol. 2013;25(6):569-578