Subtalar fracture-dislocations in children are unusual, perhaps because of the greater elasticity of bone in children. The authors have presented a case of medial subtalar dislocation in a 13-year-old boy, accompanied by a rare fracture of the entire posterior process of the talus. This particular fracture has not been previously reported in association with a subtalar joint dislocation, nor has it been reported in a child. The patient was treated successfully by closed reduction of both the dislocation and the fractures.
On the basis of the authors' results in treating avulsion fractures of the tuberosity, immobilization in a short leg weightbearing cast for 4 weeks is the preferred treatment. If still symptomatic at 4 weeks, some patients may require further immobilization for an additional 1 to 3 weeks. Rarely do these patients require surgery. In patients with these types of fractures, no angulation or displacement deformity was seen on x-rays, so open reduction was not warranted. Although the study does not strongly support the view that delayed healing of Jones fractures is associated with weightbearing cast treatment, the authors still tend to recommend treatment with a short leg nonweightbearing plaster cast for 6 weeks. Patients may not tolerate such treatment for this amount of time. To encourage better patient compliance, a minimum of 3 to 4 weeks in a nonweightbearing cast followed by 3 weeks in a weightbearing cast is recommended. Although open reduction was indicated in a few cases, all patients with Jones fractures, aged 20, 22, 24, 24, and 27 years, declined that option. Specifically, one patient had a delayed union of the Jones-type fracture (Fig. 4). In spite of being young and athletic, and thus at high risk for refracture, he decided against open reduction internal fixation and opted for prolonged casting.
This patient required reconstructive surgery for a productive life, free of pain. The use of desmopressin provided effective hemostasis and avoided the transfusion of potentially hazardous blood products.