An unlucky combination: a rare case of talus and scaphoid pseudarthrosis

R. A. Mazzucchelli, J. Mueller, C. Candrian

Objective

Is to report a rare case of talus and scaphoid pseudarthrosis in the same patient with a review of the literature.

Methods

A 59-year old man without previous medical history sustained a motorcycle accident abroad during a holiday. A fracture of the left lateral malleolus was diagnosed at the local hospital. Upon returning back to Switzerland, conservative treatment of the malleolar fracture with a cast and partial weight bearing was established. Three months later the patient was complaining left-sided foot and wrist pain and was readmitted to the emergency department. At that time X-ray showed an undisplaced talar neck fracture (Hawkins Type I) and a scaphoid fracture of the left wrist. Conservative treatment with allowed full weight bearing was carried on without any improvement. Seven months after the initial trauma, CT-scans of the ankle and the wrist were performed showing a complete non-union of both the talar neck and the scaphoid. Resection of the pseudarthrosis of the talus, cancellous bone grafting from the iliac crest and stabilization with 4.5mm HCS screws was performed. The scaphoid was revised with tricortical bone graft and fixed with a compression screw in a classical Matti-Russe Technique.

Results

The postoperative recovery was uneventful. After six weeks of partial weight bearing, the patient could switch to full weight bearing showing notable improvement. Six months after surgery the patient was completely symptomless and showed excellent bone consolidation on X-ray.

Conclusion

Both talus and scaphoid fractures are difficult to diagnose on plain X-rays and should not be missed upon assessing a patient. Whereas scaphoid fractures are well known for causing painful non-unions, there are no reported cases in the literature of pseudarthrosis after undisplaced talar neck fractures Hawkins Type I. A review of the literature shows an overall risk of 5,7% for an avascular necrosis of the talus body after Hawkins Type I fractures. Malunions or Non-unions are only described as a consequence of displaced fractures of the neck of the Talus Type II-IV. In our special case, healing of the talus was achieved with bone grafting and stabilization with screws. In conclusion, patients with a normal X-ray, persisting pain and clinically only a slight suspicion of a fracture should nowadays undergo a CT scan without delay.

Image 1 and Image 2: X-ray of the left ankle showing an undisplaced talar neck fracture
Image 3: Non-union of the talar neck on CT-scan
Image 4: Pseudarthrosis of the scaphoid
Image 5 and Image 6: Intraoperative imaging of internal fixation of the talar neck
Image 7: Postoperative situation 6 months after surgery
Image 8: Postoperative situation 6 months after surgery