A combination of bimalleolar fracture and fracture on talar body and neck: A rare case report

RATIONALE: Talar fracture accompanied with malleolar fracture is rare, and its management is complex. Ankle soft tissue is much thinner than other parts of the human body, and the shape of the ankle makes wounds difficult to close immediately after surgery, which may result in poor skin condition if the wound tension is too high. However, joint congruity and osteonecrosis are the main concerns of talar fracture. PATIENT CONCERNS: A 57-year-old man presented at the emergency department following a motorcycle accident. DIAGNOSES: Physical examination revealed swelling and tenderness of the left ankle and midfoot. The patient had comminuted talar fracture and was indicated for dual-screw fixation or even plate with screw fixation. INTERVENTIONS: We performed single screw fixation after assessing the soft tissue condition and employed a technique of using continuous longitudinal force to bring together fracture fragments (ankle ligamentotaxis) during surgery. Open reduction with a mini-hook plate and tension band wire was used for bimalleolar fracture repair using the combined anteromedial and anterolateral approach with extension of the incision. Kirschner wire for temporary fixation was performed using ligamentotaxis, and a 2.4 headless screw was inserted from the posteromedial to the anterolateral direction. OUTCOMES: The patient was discharged with a standard short leg splint and was instructed not to bear weight on the affected ankle for 2 months. The patient walked well without discomfort, and the Hawkins sign was clearly visible. Single screw fixation preserves the integrity of the talus bone as minimal space is used for this operative technique. Single screw fixation preserves more bony stock when most of the internal fixator is located within the bone. Additionally, surgery time is shorter than multiple implantations even when performing the same procedure; as a result, there was less ankle soft tissue swelling. LESSONS: This case provides evidence of using the single screw fixation technique for addressing both malleolar and talar fractures, and that talar fracture management can be less aggressive with limited weight bearing and initial limited range of motion given the presence of malleolar fracture. The alignment and stability of bony fragments also benefit from ankle ligamentotaxis.