Mickel TJ, Andersen R, Keeling J, McKenna P. Foot Ankle Int. Talar Fractures and Dislocations: A Radiologist's Guide to Timely Diagnosis and Classification. And so flex means to pull down, hallucis just refers to the big toe because the hallux is actually the medical term for your big toe, and longus means that its long. Watanabe, H., Majima, T., Takahashi, K., Kawaji, H. & Takai, S. Split fracture of the posteromedial tubercle of the talus: case report and proposed classification system. Percutaneous screw fixation treatment with computer-assisted three-dimensional evaluation shortened the operation time and reduced incidences of surgical complications. Veazey, B. L., Heckman, J. D., Galindo, M. J. How your fracture is treated depends on which type it is and what caused it. https://doi.org/10.1097/BPB.0b013e328351419c (2012). - inversion of ankle may avulse tubercle leaving PTFL intact; Open Access This article is licensed under a Creative Commons Attribution 4.0 International License, which permits use, sharing, adaptation, distribution and reproduction in any medium or format, as long as you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons licence, and indicate if changes were made. That ones longer, so its called the flexor hallucis longus tendon. TALAR NECK FRACTURES Most common type of Talar Fractures It is so called, if # inferior line is distal to Lateral process of Talus AVIATORS ASTRAGALUS : Pilots resting the sole of the foot on the rudder bar in crashing plane at the point of impact causes Hyperdorsiflexion of ankle causing Talar neck # . There were no significant differences for AOFAS scores and VAS scores between the two groups at 4 and 12months postoperatively (p>0.05) (Tables 1,2). The injuries can be divided anatomically into osteochondral, lateral process, posterior process, and true body (dome) fractures. Fractures of talar posterior process are very uncommon injuries as these fractures cannot be discovered with standard X-ray 1,2.This type of fracture may result in severe complications due to . If your fracture is stable and your joints are well-aligned, surgery may not be necessary. Typically, surgeons will immobilize the ankle and allow the incisions to heal before initiating physical therapy. Mao, H., Wang, H., Wang, L. & Yao, L. Definition of a safe zone for screw fixation of posterior talar process fracture by 3-dimensional technology. Radiographics. S92.101A initial encounter for closed fracture; S92 . 27824 - Closed treatment of fracture of weight bearing articular portion of distal tibia (pilon or tibial plafond), with or without anesthesia. The posterior talar process fracture is an uncommon fracture and is frequently undiagnosed by orthopaedic surgeons. 3). Jonathan Cluett, MD, is a board-certified orthopedic surgeon with subspecialty training in sports medicine and arthroscopic surgery. Data Trace specializes in Legal and Medical Publishing, Risk Management Programs, Continuing Education and Association Management. The posteromedial process fracture of the talus: a case report. A survey of OTA members. A surgical technique for treatment of posteromedial talus fractures involving both the ankle and subtalar articulations is described in detail and results in 10 patients treated successfully with this technique are reviewed. But if you have chronic pain, if you think you have posterior ankle pain where you might have problems with your posterior process, or you think maybe you sprained your ankle and maybe somethings broken and got missed, join us for the masterclass, the web class that we do on ankle pain in runners, and I think youll learn a lot about some of the things you can check all on your own, and some other questions you can ask your doctor so that you can make sure that you can get that better and get back to running as quickly as possible. The talus is shaped like a truncated cone and is wider anteriorly than posteriorly,which creates greater ankle stability in dorsiflexion. Surg. Subsequently, the best surgical approach is still in controversy. Foot Ankle Int. In the meantime, to ensure continued support, we are displaying the site without styles [Surgical management of talus fractures: mid-term functional and radiographic outcomes]. Axial view of CT scans showing that the internal fixation was performed properly. Isolated breaks are rare, and, when they do happen, they tend to be difficult to reduce (reset) and fixate (stabilize).. & McGanity, P. L. Excision of ununited fractures of the posterior process of the talus: a treatment for chronic posterior ankle pain. Federal government websites often end in .gov or .mil. Mao, H., Shi, Z., Liu, Z., Wang, H. & Xu, D. Minimally invasive technique for medial subtalar dislocation associated with navicular and entire posterior talar process fracture: a case report. Excellent and good results were achieved in eight (66.7%) patients, fair results were achieved in three (25%), and poor results were observed (8.3%) for the last follow-up. You can break your talus in a trauma like a fall or car accident. 56, 187190. So sometimes a posterior process is an actual fracture, and sometimes it's a natural occurrence where the bone just hasn't fully ossified, and technically you have this other thing called an Os trigonum it doesn't really matter the specifics of the terms or what that means, it just means you have a natural separation of the two pieces . The calcaneus forms the bony part of the heel. A closed reduction and internal fixation of the posterior process of the talus using a minimally invasive approach was performed, based on the images from the preoperational simulations (Fig. Initial assessment of treatment of talar posterior process fractures with open reduction and percutaneous fixation. Access and reduction of displaced or comminuted fracture fragments is a challenging procedure for surgeons due to the rarity of fractures of entire posterior process. It is necessary to avoid complications of pain, nonunion and tarsal tunnel syndrome for the treatment of these fractures3,4,5. Tape it and forget it. It will be this fragment where fixation efforts will be focused. However, it is apparent that . Individuals who have suffered a major foot injury due to the negligence of another person or entity should contact me at (800) 404-5400 and/or (209) 227-1931 to receive free, friendly legal guidance and advice. Letonoff, E. J., Najarian, C. B. Tibia sebanyak 59.5% dibanding pada remaja mempunyai ujung atas yang melebar dan (16-19 tahun) sebanyak 31.8%, dan anak- ujung bawah yang lebih kecil, serta sebuah anak (1-16 tahun) 8.7%.6 Tempat paling corpus.10 sering terjadinya . It should be noted, that the AOFAS score is currently not validated for most authors in the literature. - decreased & painful motion of ankle and subtalar joints; When most people describe an ankle fracture, they generally mean it to involve lower parts of the tibia and/or fibula. Therefore, most authors in the literature consider that if the displacement of the fracture fragment is larger than 2mm and subtalar joint surface is involved, then an urgent open reduction and internal fixation is recommended9,16. This approach is especially suitable for patients who have multiple comorbidities and a higher perioperative risk. Trauma 10, 142144. A lateral talus fracture (snowboarders fracture) occurs when your ankle is forced outward while a stress fracture to the Talus bone is a less common type of talus fracture, that usually occurs due to repetitive impact. 51, 326329. Update on talar fracture patterns: a large level I trauma center study. Wolf, R. S. & Heckman, J. D. Case report: fracture of the posterior medial tubercle of the talus secondary to direct trauma. Use of a 30-Degree External Rotation View for Posteromedial Tubercle Fractures of the Talus. The posterior talofibular ligament attaches to the lateral tubercle and flexor hallucis longus runs between these two tubercles. - Frx of Lateral Tubercle of Posterior Process (Sheppard's Frx): 1,2,3,4,5,6,7,8,9,10,11,12,13,14,15,16,17 In a . Diagnosis of medial tubercle fractures of the talar posterior process using oblique views. PubMed Further, a trial of cast immobilization of acute posterior or lateral talar process fractures of at least 6 weeks is useful, . PubMedGoogle Scholar. There are few studies about this injury in the literature and most of them are case reports6,18,25. The majority of posterior process fractures cases are associated with concomitant subtalar dislocation. Clin. Data Trace is the publisher of Internal fixation was designed to perform as internal fixation compression with a cannulated screw. A bone fracture is the medical term for breaking a bone. 2, 10, 11 Non weight-bearing and short leg casts are recommended for 4 to 6 weeks followed by 2 weeks of weight bearing to tolerance. 28400 - Closed treatment of calcaneal fracture. The types of fractures that the patients exhibited were one lateral tubercle fracture, three medial tubercle fractures and eight entire posterior process fractures. Romeo, N. M., Hirschfeld, A. G., Githens, M., Benirschke, S. K. & Firoozabadi, R. Significance of lateral process fractures associated with talar neck and body fractures. J. J. Vasc. the posterior and the lateral. Fractures of the posterior process of the talus are rarely seen and frequently overlooked. Internet Explorer). Treatment of an avulsion fracture typically includes resting and icing the affected area, followed by controlled exercises that help restore range of motion, improve muscle strength and promote bone healing. Talar fractures comprise 3%-5% of all foot and an- . Look-Ups. Epub 2012 Feb 21. Eisenstein N, Hillier D, Ahmad S: Medial subtalar dislocation with navicular and posterior talar process fracture: the first report in the literature. You'll need some form of immobilization like a splint or cast and might need surgery to . So unfortunately, if you have an injury and we go looking for your trouble, as soon as we find something, well, a lot of times doctors see it and they think, well, thats the problem, and they make the diagnosis of that thing, but then they miss the other thing sometimes. The mechanism of injury may result from a posteromedial facet impaction17. CAS The Cedells fracture was first described as a medial tubercle fracture due to talotibial ligament avulsion. Early diagnosis and timely determination of the displacement of the fracture are necessary for the choice between the using of percutaneous screw or ORIF technique. 2,8 . Foot Ankle 13, 453457 (1992). Previous reports have described that ORIF treatment leads to a different outcome9,16. This is why postoperative care will often require the ankle to be non-weight-bearing for six weeks. - minimally displaced fractures are treated w/ short leg cast for 4 to 6 weeks; Citation, DOI & article data. - clinical findings: Orthopaedic Specialists of North Carolina. Key words: talus, fracture, talar neck, talar head, talar body, lateral process, posterior process, talar extrusion, orthopaedic surgery, review. 41, 5256 (2002). American Academy of Orthopaedic Surgeons. Fracture patterns provide clues to the underlying pathomechanics and energy of the injury, both of which can help guide treatment and suggest prognosis. Please enable it to take advantage of the complete set of features! Less serious injuries may. the best experience, we recommend you use a more up to date browser (or turn off compatibility mode in Copyright 2015. Fractures of the anterior process account for approximately 15 percent of all calcaneal fractures and are commonly misdiagnosed as ankle sprains. In some other animals, it is the . Treatment of posterior ankle pain by excision of a bipartite talar fragment, Clifford R. Wheeless, III, M.D. If suspected, a computed tomography (CT) scan is generally preferred over an X-ray or MRI. The CT scan allows the surgeon to clearly see how many fragments there are and helps determine where the major fragment is located. Ankle fractures (broken ankle). Created for people with ongoing healthcare needs but benefits everyone. All CT scans were performed using a 256-slice Siemens CT scan (GE, United States) with 1.0mm slices at 0.1s intervals for the foot and ankle imaging. Once the posterior tibial neurovascular bundle and the flexor hallucis longus tendon were identified, they were retracted medially to achieve excellent exposure of the medial tubercle, lateral tubercle and FHL tendon groove (Fig. Radiographic examination revealed a tibia plafond fracture, a distal fibula fracture and a talo-tibial divergent fracture-dislocation in the right lower extremity; while in the left lower extremity there was a fracture of the medial malleolus and an 81C3 talus body fracture according to the OTA classification. J. The unfused ossification center of the lateral tubercle forms the os trigonum. Surgery will often be required to ensure the fragments are correctly placed. The patient can be immobilized in a short-leg walking cast with the foot in 15 degrees of equinus for 4-6 weeks [ 12 ]. Some fractures involve both bones; others affect only one. BMC Musculoskelet. Abdelgaid, S. M. & Ezzat, F. F. Percutaneous reduction and screw fixation of fracture neck talus. Well that thing curves right down around the back of the ankle, and if you get a fracture or a crack in that part of the talus, when you roll your ankle really, really badly, well that can cause chronic pain, because what happens is that you get a little crack there, and every time you take a step, youve got the FHL tendon (flexor hallucis longus) going right around here and it wraps around as it goes down around the bottom of your foot, and every time you take a step and you pull down with the big toe, it actually pulls on the posterior process fracture and it moves it and that causes pain. https://doi.org/10.1016/j.injury.2014.12.002 (2015). The most common site of talus fractures is at the talar neck followed by the lateral process. For clinical assessment, considerable improvements were observed for the AOFAS and VAS scores at 4 and 12months postoperatively in both techniques. Sci Rep 10, 20221 (2020). With that being said, there remains controversy as to when it is most appropriate. also known as broken ankle , ankle fracture and malleoli fracture . S92.101 Unspecified fracture of right talus. Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations. #432 3 reasons runners get black toenails, #434 Top 3 tips to avoid bruising your toenails during long runs . talar neck fracture with posteromedial extrusion of the talar body should be treated operatively, even in patients with significant neuropathy, to relieve soft-tissue and/or neurovascular compromise. Recognizing the influence of the anatomic region on the accuracy of assessing the screw position preoperatively can help the surgeon avoid placing screws that penetrate the articular facet or injuring the neurovascular bundle and tendon, as described in previous literature8,15. Diagnosis of medial tubercle fractures of the talar posterior process using oblique views. Further-more, the fractures of the medial . In some cases, the bone will not need to be repositioned, and the fragment can be secured without surgery. Intraoperative photo of percutaneous screw implanted with the minimally invasive technique. Amoretti, N. & Huwart, L. Percutaneous screw fixation of a talar fracture under computed tomography and fluoroscopy guidance. The images or other third party material in this article are included in the article's Creative Commons licence, unless indicated otherwise in a credit line to the material. Clinical outcome and concomitant injuries in operatively treated fractures of the lateral process of the talus. J. More often, breaks will occur when the medial and lateral malleolus are also involved. 2013 Nov;201(5):1087-92. doi: 10.2214/AJR.12.9918. Mao, H., Wang, H., Zhao, J. et al. An avulsion fracture occurs when a small chunk of bone attached to a tendon or ligament gets pulled away from the main part of the bone. Moreover, there is little consensus on how best to stabilize the fracture once it has been reset. J. https://doi.org/10.1177/107110079801900414 (1998). Answer From Edward R. Laskowski, M.D. Open Orthop J. You may have to wear a cast or splint to prevent further damage. entire posterior process fractures). The neck has approximately 15 to 20 of medial deviation and is the area most vulnerable to fractures. The wound was closed and stabilized using a dry and sterile bandage, then a below-knee splint was applied, and patients were permitted non-weight bearing mobility with the use of crutches. talar body fractures were studied retrospectively to assess outcome after operative treatment. The achieved position of each screw was verified using the 3D reconstructions and three different 2D images, taken in three different planes (axial, coronal and sagittal), thus enabling assessment of potential perforation into the subtalar or the ankle joint15. TIBIAL STRESS FRACTURE Reza Maulana Abstrak. Sign up for the Nature Briefing newsletter what matters in science, free to your inbox daily. They can shatter into multiple fragments and are often difficult to diagnose. The experiment was conducted in accordance with the Declaration of Helsinki (World Medical Association). Initial assessment of short-term results in patients who underwent internal fixation using ORIF and percutaneous screw techniques for posterior talar process fracture was performed in this study. Among a total of 12 patients have undergone pre and post-operative 3D-CT. 33, 871880. https://doi.org/10.1053/j.jfas.2012.02.007 (2012). Safe Zone of Posterior Screw Insertion for Talar Neck Fractures on 3-Dimensional Reconstruction Model. Cannulated screws are recommended for fracture fixation with small fracture fragments and articular cartridge. The posteromedial approach is a popular incision, used by the majority of surgeons. Knowledge of the exact fracture fragment and safe zone of fracture fixation can help reduce the risk of joint penetration and neurovascular bundle damage. Biomechanical efficacy of four different dual screws fixations in treatment of talus neck fracture: a three-dimensional finite element analysis. Occult talar neck fracture associated with talar avulsion diagnosed by MRI: a case report. To the authors knowledge, there are few descriptions of surgical techniques for fractures of posterior talar process in the literature8,13,19. Average follow-up was 26 months (range: 18-43). The clinical and radiological results were assessed after 4 and 12months of operation with Visual Analog Scale (VAS) pain and American Orthopedic Foot and Ankle Society (AOFAS) scores. Talar dome injuries occur equally in men and women. Type 4 talus fractures include not only the dislocation of the body of the talus (the posterior portion) from the calcaneus but also the separation of the head of the talus from the other tarsal bones anterior to it. Shibuya et al (PMID: 24785202) found that open fractures occur in approximately 20% of calcaneus and talus fractures. Treatment relies on appropriate diagnosis, which hinges on clinical suspicion provided by the patient's account of pathomechanics, clinical examination, and radiological workup. anteroposterior, mortise and lateral views). Because the ankle is vulnerable to twists and compression, the fracture of these bones is not uncommon and can sometimes be difficult to treat. Verywell Health's content is for informational and educational purposes only. This is commonly referred to as a trimalleolar fracture in which all three bone structures are broken. Another limitation is the validity and reliability of the AOFAS and VAS score system, which is not universally examined and accepted. The talus is a small bone of the ankle responsible for transferring weight bearing forces from the shin to the foot (figure 1). & Grenier, J. M. Fracture of the lateral tubercle of the posterior talar process caused by a rock-climbing fall: a case report. Injury 46, 759762. Based on their description, lateral and posterior process fractures are classified into four types. Description. S92.1 Fracture of talus. Elevating the foot above the level of the heart helps to minimize swelling and pain. Article Your doctor may give you pain relief medications to help reduce swelling. Though uncommon, in some cases, people may need to undergo surgery to have the surgical hardware removed later on down the road. The yellow arrow is a cannulated screw. In our study, anatomical observation and classification of the posterior process of the talus were carried out, and related imaging and finite element methods were combined. If the symptoms persist; an additional period of immobilization (4 to 6 weeks) might be required. A CT scan is recommended in order to reveal the fracture type and assess the displacement of the fracture fragment12,29. She got back to running, but shes had intermittent pain in the back of her ankle, not at the same place where she got the sprain, but shes had this pain thats been going on for a long time, and then she got an x-ray and someone told her she might have a posterior process fracture of the talus, but they didnt really explain exactly what that was, and so she was told to take some time off of running for a little while and see if it improves. Correlation factors for distal syndesmosis ossification following internal fixation of ankle fracture, A comparative study of operative and conservative treatment of intraarticular displaced calcaneal fractures, Arthroscopy Assisted Reduction Percutaneous Internal Fixation versus Open Reduction Internal Fixation for Low Energy Tibia Plateau Fractures, A new surgical strategy for the treatment of tibial pilon fractures with MIPO facilitated by double reverse traction repositor, Application of the multiplanar fracture redactor in the treatment of tibial shaft fractures with intramedullary nails, Dual plating or dual plating combined with compression bolts for bicondylar tibial plateau fractures: a retrospective comparative study, The limitations of fully threaded screws in isolated percutaneous transarticular screw fixation of C1/C2, Comparison of Clinical Efficacy of Lateral and Lateral and Medial Double-plating Fixation of Distal Femoral Fractures, Low occupancy rate of the pedicle screw in the vertebral body leads to upper instrumented vertebral fracture, https://doi.org/10.1097/BOT.0b013e31804ea0d9, https://doi.org/10.1177/107110079601700408, https://doi.org/10.1016/j.injury.2014.12.002, https://doi.org/10.1097/BPB.0b013e328351419c, https://doi.org/10.1007/s00402-007-0459-8, https://doi.org/10.1302/2058-5241.3.170040, https://doi.org/10.1016/j.fas.2018.11.013, https://doi.org/10.1053/j.jfas.2016.02.001, https://doi.org/10.1097/MD.0000000000013331, https://doi.org/10.1177/107110079801900414, https://doi.org/10.1053/j.jfas.2012.02.007, https://doi.org/10.3109/08941939.2012.740146, https://doi.org/10.1016/j.injury.2007.04.025, https://doi.org/10.1111/j.1445-2197.1987.tb01441.x, https://doi.org/10.1177/107110079801900915, https://doi.org/10.1186/s12891-019-2603-3, https://doi.org/10.1097/00005131-199602000-00014, https://doi.org/10.1016/j.fas.2012.01.003, https://doi.org/10.1016/j.jvir.2012.09.006, https://doi.org/10.1097/BOT.0000000000001326, http://creativecommons.org/licenses/by/4.0/, Anatomical observation, classification, fracture and finite element analysis of the posterior process of the Asian adult talus. 14 As expected, there seems to be a trend of increased complication rates with a longer follow-up . Towson, MD 21204 2017;11:732-742. doi:10.2174/1874325001711010732, Gibson PD, Bercik MJ, Ippolito JA, et al. Foot and Ankle 10, 235238 (1990). https://doi.org/10.3109/08941939.2012.740146 (2013). official website and that any information you provide is encrypted Minimal displacement of fracture fragment with percutaneous screw fixation was recommended. volume10, Articlenumber:20221 (2020) Accessibility Orthopaed. The statistical significance of the difference between the groups was determined at the 0.05 significance level15. A., Okereke, E. & Williams, G. R. Jr. Open medial subtalar dislocation associated with fracture of the posterior process of the talus. The clinical data was offered by K.W.. S92.10 Unspecified fracture of talus. Google Scholar. This project was supported by the medical and health science and technology project of Zhejiang Province (2015KYB339) and Ningbo Natural Science Foundation (2018A610266). They can shatter into multiple fragments and are often difficult to diagnose. Today on the Doc On The Run Podcast were talking about posterior process fractures of the talus. The study provided valuable information for the minimally invasive technique of posterior talar process fracture and contributed to the accuracy of this highly demanding technique. ( 20 tahun) paling tinggi dengan talus dan ujung distal fibula. 2020 Feb 11;15(1):45. doi: 10.1186/s13018-020-1560-8. posterior process consist of medial and lateral tubercles separated by groove for FHL Navicular bone Sustenaculum tali Blood supply talar neck supplied by three sources posterior tibial artery via artery of tarsal canal (dominant supply) supplies majority of talar body deltoid branch of posterior tibial artery supplies medial portion of talar body This site needs JavaScript to work properly. And sometimes patients are told that they have a posterior process fracture when they really dont. The ankle joint is a complex junction of three bones known as the fibula, tibia, and talus. (A) Medial ankle; (B) achilles tendon; (C) entry point of percutaneous screw. PMC A minimally invasive approach for this fracture was described, which is an attractive alternative compared to major open operation. Horterer, H. et al. The small fragments were fixed using Kirschner wire and 3.0mm headless cannulated screws were used to fix the minimal displacement of fracture fragment or comminuted fracture. Defination: a pott's fracture is a type of ankle fracture that is characterized by a break in one or more bony prominences on the sides of the ankle known as the malleoli . AJR Am J Roentgenol. Orthopaed. J. and transmitted securely. In addition, the short follow-up time might have not been adequate for complications such as ankle and subtalar joint osteoarthritis to develop. Statistical analysis was performed using the Statistical Package for Social Sciences (SPSS, IBM) version 20.0. Avulsion fractures of the medial tubercle of the posterior process of the talus. And so what does that mean? Carousel with three slides shown at a time. No patients complained of stiffness in the ankle and subtalar joint. Seven patients exhibited posterior process fractures associated with concomitant subtalar dislocation, three talar body involvement and two concomitant avulsion fracture of lateral malleolus. The role of computed tomography in surgical planning for trimalleolar fracture. Another way to do this is to go through dorsiflexion with a posterior glide on the talus. Previously, we described a case and defined a safe zone for percutaneous screw fixation8,15. This allows your surgeon to reposition the fragments and secure them with plates and screws. doi: 10.1016/j.cpm.2012.01.005. And I give lectures at medical conferences about subtle fracture patterns, Ive been doing that for about 10 years or so, lecturing at medical conferences on this topic, because I did some research on another rare fracture called a Lateral Process Fracture, and in that study we actually looked at all of these patients that came into the hospitals and clinics over a three-year period, and what we found is that if a posterior process fracture was noticed on the x-ray, there was actually a statistical probability that you would also have a Lateral Process Fracture. The goal is to have the bones heal as closely to perfect as possible so as to prevent any residual instability or malalignment of the bone. The ORIF technique with posteromedial approach was a good option for comminuted fracture and supported by previous literature19. Ebraheim, N. A. et al. Valderrabano, V., Perren, T., Ryf, C., Rillmann, P. & Hintermann, B. Snowboarder's talus fracture: treatment outcome of 20 cases after 3.5 years. Well, the back of your ankle is the posterior aspect of your ankle, and the back of the talus is where the posterior process is. and J.Z. Total recovery time is between four to six months, although it may take longer for more severe injuries. Google Scholar. The scores using the percutaneous screw technique were improved from 63.5 to 84.1 at 4months postoperatively and to 83.9 at 12months postoperatively (Table 1). 2017;31(4):e116-e120. The minimally invasive surgical technique of fracture fixation was modified according to the method described in Mao et al.8,15. Invest. Normally a towel or rope works well. In general, these injuries are described as tibial plafond fractures (plafond referring the part of the tibia where joint articulation occurs). Clinical and radiological outcomes of patients were assessed at 4 and 12months postoperatively. This study provided insight into our previous experience using percutaneous screw fixation and ORIF techniques for the treatment of posterior talar process fracture with clinical outcome assessment. The posterior process is this big bump that you see sitting on the back of the talus sitting over your heel bone. Nondisplaced fractures can be managed with a trial of nonoperative immobilization. Talus fractures are significant because of their potential for long-term morbidity and complications. Talus fracture treatment algorithm . Fracture patterns provide clues to the underlying pathomechanics and energy of the injury, both of which can help guide treatment and suggest prognosis. Scand. The purpose of this study was to provide an initial assessment of treatment for talar posterior process fractures using open reduction and internal fixation (ORIF) through posteromedial approach and percutaneous screw fixation. Diagnosing and Treating Posterior Malleolus Fractures. Therefore, this technique is the most common treatment described in previous literature12,13,14. Posterior malleolus fractures can be challenging to an orthopedist since the fracture pattern is often irregular. The incision is located at the middle line between the Achilles tendon and the medial border of the medial malleolus19. Foot Ankle Surg. Simulation of inserting the virtual computer-aided design (CAD) screw (diameter 3.0mm) was performed, after obtaining three-dimensional (3D) reconstructions of original CT scans. Fig. Article Yaw Boachie-Adjei, MD, is a board-certified, double-fellowship Orthopedic Surgeon. 3, 8592. If that happens and you have chronic pain, well, you need to address it. POSTERIOR . - lateral tubercle has an articular surface, & frx thru this tubercle is often associatted w/ arthrosis; - Frx of Medial Tubercle: Unable to load your collection due to an error, Unable to load your delegates due to an error. TREATMENT Goals of treatment: 1. https://doi.org/10.1097/BOT.0000000000001326 (2018). posterior process consist of medial and lateral tubercle separated by groove for FHL Blood supply because of limited soft tissue attachments, the talus has a direct extra-osseous blood supply sources include posterior tibial artery via artery of tarsal canal (most important and main supply) supplies most of talar body via calcaneal braches Repeat surgical intervention after an index treatment of a talus fracture can stem from treatment of infection, reconstruction of a malunion, revision fixation of a nonunion, or fusion/joint reconstruction of post . The postoperative VAS and AOFAS scores were comparable, with no significant differences between the two techniques. The patient is a 27-year-old male with left talar neck fracture (Hawkins type-2) (a, b).The X-ray after closed reduction showed a good position (c, d).Percutaneous insertion of guide wires and screws from posterior to anterior were used along the guide wires for fixation (e, f).Hawkins sign was found at eight weeks post-operatively (g, h).The follow-up CT showed that the fracture was union . 2019 Aug 7;20(1):363. doi: 10.1186/s12891-019-2738-2. Mobilization and protection of the neurovascular bundle is essential when accessing the fracture site. The 3D model with medial and lateral virtual screw path of the posterior talar process. https://doi.org/10.1016/j.jvir.2012.09.006 (2012). Int J Surg Case Rep. 2017;41:360-365. doi:10.1016/j.ijscr.2017.10.062. Initial treatment of posterior impingement . Entire posterior process fractures are easier to identify than isolated medial or lateral tubercle fractures on plain radiographs. Implementation of the minimally invasive technique allows easy access for fracture fixation, minimization of intraoperative risk of traction lesion of neurovascular structures, and shortening of operation time and rehabilitation period. https://doi.org/10.1038/s41598-020-77151-6, DOI: https://doi.org/10.1038/s41598-020-77151-6. Twelve Asian patients with talar posterior process fracture were treated with two techniques and followed up in this study. doi:10.1097/BOT.0000000000000763, Smeeing DPJ, Houwert RM, Kruyt MC, Hietbrink F. The isolated posterior malleolar fracture and syndesmotic instability: a case report and review of the literature. Correspondence to One or two 3.0mm cannulated screws were applied as a lag screw function (Fig. Most avulsion fractures heal very well without surgical intervention. The widely preferred approach for many talar neck and body fractures is a dual anterior incision technique to achieve an anatomic reduction, with the addition of a medial malleolar osteotomy as needed to visualize the posterior talar body. Symptoms of a Talus Fracture Talus Fracture symptoms vary depending on the type of fracture. Mehrpour, S. R., Aghamirsalim, M. R., Sheshvan, M. K. & Sorbi, R. Entire posterior process talus fracture: a report of two cases. Talus fractures have a wide variety of presentation from low-energy avulsion fractures of the lateral or posterior processes, to high-energy comminuted talar body fractures. There was no significant difference for AOFAS scores and VAS scores between the two techniques (p>0.05). Bookshelf From January 2014 to December 2018, 12 cases with displaced fracture of talar posterior process were treated in our department. A talus fracture is a condition characterized by a break in one of the small bones of the ankle, known as the talus (figure 1). Serbest S, Tiftiki U, Tosun HB, Kesgin E, Karata M. Isolated posterior malleolus fracture: a rare injury mechanism. The talar avulsion fracture in this patient is also small with only slight displacement and is seen hovering just above the mid to anterior talus. The majority of the talus is articular cartilage so screws may be passed from posterior to anterior through the small non-articular portion of the bone. If a fracture wassuspected with plain radiographs, then an urgent CT scan wasrecommended in order to identify the fracture and assess the size and fracture fragment. & Yi, X. Posteromedial approach in treatment of talar posterior process fractures. An official website of the United States government. Shi, Z., Zou, J. Avulsion fractures of the medial tubercle of the posterior process of the talus. Clipboard, Search History, and several other advanced features are temporarily unavailable. The .gov means its official. and JavaScript. There was no evident difference between the two, according to clinical assessment. Watch on. 17, 226229. Intraoperative photo of ORIF. Most reports of talar posterior process fractures are associated with subtalar dislocation7,8,9 and the recommended treatment is early open reduction and internal fixation (ORIF) or percutaneous screw fixation8. Therefore, adoption of the surgical option depends on the degree of joint involvement and the degree of displacement of the posterior process fragment. Clinical outcome of closed isolated subtalar dislocations. Because an isolated fracture of this sort is so rare, diagnoses are sometimes missed or inconclusive. Trauma 32, 601606. Majeed, H. & McBride, D. J. Talar process fractures: an overview and update of the literature. Physical therapy consisting of passive and active assisted and resisted ankle range-of-motion exercises was performed during these days8. Fracture of the posterior process of the talus is an uncommon injury that is often missed on plain X-Ray and misdiagnosed as ankle sprain. 2008 Sep;29(9):956-8. doi: 10.3113/FAI.2008.0956. Scientific Reports (Sci Rep) To the authors knowledge, there is no literature on which treatment is a better option between ORIF and percutaneous screw for posterior talar process fracture. Would you like email updates of new search results? And because the tissue is relatively thin there, it is not uncommon to have an open fracture (one in which the skin is broken). Further future, randomized trials will help determine whether percutaneous screw fixation associated with posterior talar process fracture truly influences the rate of subtalar arthritis formation when compared with the ORIF technique with posteromedial approach. Surgery is the definitive treatment, indicated especially for open or displaced fractures. PubMed Biz C, Golin N, De Cicco M, Maschio N, Fantoni I, Frizziero A, Belluzzi E, Ruggieri P. BMC Musculoskelet Disord. J. 2022 Dotdash Media, Inc. All rights reserved. in posterior impingement is believed to be the result of bone impaction and thus represents bone contusions or occult fractures. The Mann Whitney U test was used for the skewed distribution of cases. Foot Ankle Int. Fractures of talar posterior process involve an isolated fracture of either medial or lateral tubercle and simultaneous fracture of the medial and lateral tubercles (entire posterior process fractures)4,6. https://doi.org/10.1097/MD.0000000000013331 (2018). Choice of optimal treatment methods depends on fragment size, degree of displacement, subtalar joint involvement and articular surface intervention. The fractures were classified as coronal (11), sagittal (6) and crush fractures (2). Skin incision was performed from the medial malleolus proximally to the calcaneal tuberosity distally and then the incision was continued along the middle line between the anterior edge of the Achilles tendon and the posterior border of the medial malleolus. Radiol. The percutaneous screw fixation and ORIF techniques were performed for posterior talar process fracture in accordance with fracture displacements. Relat. Telephone: 410.494.4994. The technique involved placing one or two cannulated screws to stabilize the fracture with percutaneous screw fixation. Diagnosis of medial tubercle fractures of the talar posterior process using oblique views. Treatment may involve wearing a short leg cast or a removable brace. Trauma 21, 579582. Naranja, R. J. Jr., Monaghan, B. J. No complications such as screw loosening, nonunion, or malunion were reported and no patients complained about stiffness of the ankle and subtalar joint. doi:https://doi.org/10.1016/j.fas.2018.11.013 (2018). TREATMENT 35. Chen, Y. J., Hsu, R. W., Shih, H. N. & Huang, T. J. Fracture of the entire posterior process of talus associated with subtalar dislocation: a case report. Foot Ankle Surg. 19, 255258. The Cedell's fracture was first described as a medial tubercle fracture due to talotibial ligament avulsion. The cause of injury for eight of the cases was vehicle accident and for four of the cases sport injury. 23, 17111712. All rights resvered. PubMed Central This type of fracture may result in severe complications due to missed diagnosis, delayed or inappropriate treatment. This typically involves the separation of the posterior tibial insertion of the PCL to variable degrees. government site. - nonunions are uncommon: A minimally invasive approach, which minimized the intraoperative risk of lesion of neurovascular structures, was described and preoperative individual planning with computer-assisted three-dimensional techniques for positioned percutaneous screws was recommended. Fractures of the talus: a comprehensive review. First, you'll be placed in a splint to keep your foot and ankle from moving. Talus mobilization for ankle mobility. Seven cases of posterior process fractures associated with concomitant subtalar dislocation were reduced and stabilized by emergency cast. Fractures of both tubercles will usually be treated conservatively if there is minimal displacement. Clinical outcome based on Additionally, ORIF with posteromedial approach was recommended for fixations of fracture fragments with large displacements that may cause incongruity in the subtalar or ankle joint. Provided by the Springer Nature SharedIt content-sharing initiative, Journal of Orthopaedic Surgery and Research (2022). The site is secure. Crutches are advised initially. Res. (A) Flexor hallucis longus tendon; (B) posterior tibial artery; (C) plantar nerve. Fractures of talar posterior process have three types, namely an isolated fracture of either medial or lateral tubercle and a simultaneous fracture of medial and lateral tubercles (i.e. and L.Y. . As the bone remains aligned after the blow, it is usually easier to treat a non-displaced fracture as compared to a displaced fracture. By Jonathan Cluett, MD Foot Ankle Surg. The posterior process of the talus is composed of medial and lateral tubercles, separated by the groove for the flexor hallucis longus tendon. 4). To view a copy of this licence, visit http://creativecommons.org/licenses/by/4.0/. Use of a 30-degree external rotation view for posteromedial tubercle fractures of the talus. There were no considerable differences in AOFAS and VAS scores between the two techniques at 4 and 12months postoperatively. Immediate first aid treatment for a talus fracture, as with any painful ankle injury, is to apply a well-padded splint around the back of the foot and leg to immobilize and protect the limb. Some studies in the literature have reported that up to 40% of these fractures may be missed on initial presentation using X-ray 21,22,23. The AOFAS and VAS scores were used to analyze the treatment outcomes. The treatment recommended for small (<1 cm) and minimally displaced (<2 mm) fractures of the posterior process of the talus is conservative . Content is reviewed before publication and upon substantial updates. Read our, Bimalleolar and Trimalleolar Ankle Fractures, Medial Malleolus Fracture and Broken Ankle Treatment, Physical Therapy Exercises After a Tibial Plateau Fracture, Common Fractures of the Leg, Ankle, and Foot, The Causes and Treatment of Foot and Ankle Stress Fractures, Posterior Tibial Tendonitis Signs and Treatment, Isolated posterior malleolus fracture: a rare injury mechanism, Operative treatment of posterior malleolar fractures, The isolated posterior malleolar fracture and syndesmotic instability: a case report and review of the literature, Addressing posterior malleolar ankle fractures, The posterior malleolus situated on the lower back side of the tibia. 2015;20:123. doi:10.11604/pamj.2015.20.123.6046, Duan X, Kadakia AR. Nonsurgical treatment includes restricted weight-bearing, patellar tendon-bearing braces, and extracorporeal shockwave therapy. 6, 21, 23, 24. Mills, H. J. Tucker, D. J., Feder, J. M. & Boylan, J. P. Fractures of the lateral process of the talus: two case reports and a comprehensive literature review. The posterior talar process fractures present in the study were classified as lateral tubercle fracture, medial tubercle fracture and entire posterior process fracture. It forms a joint with the talus bone, the subtalar joint. The talus is situated below the tibia and fibula (lower leg bones) and connects with these . This technique offered a good evaluation of the fixation for talar process fractures preoperatively. Long-term radiographic and clinical-functional outcomes of isolated, displaced, closed talar neck and body fractures treated by ORIF: the timing of surgical management. This is due to attachments of ligaments between the two bones. All cases showed no screw loosening, implant breakage, nonunion, or malunion. Posterior cruciate ligament (PCL) avulsion fractures are a type of avulsion fracture of the knee that represent the most common isolated PCL lesion. Liu, Z., Zhao, Q. web1! Type of fracture may be difficult to reset and stabilize. But in either case, if your pain is on the back of your ankle and it hurts when you do stuff with your big toe, for example, if youre doing calf raises, if you stand up on the balls of your feet and your heels are way up off the ground, then youre having to pull hard with your big toe to maintain your balance in that position. Some studies reported different types of posterior process fractures, however, none of them defined an optimized approach and treatment. The study was performed by H.W. If they do that and they have pain in the back of the ankle, that can signify that you actually have inflammation of that tendon, or you have inflammation and irritation of the posterior process of the talus, so thats something to think about and check. Interv. 7). J. Orthop. Request PDF | Posterior Talar Process Fractures | A posterior talar process fracture is an uncommon injury and the literature on the subject is limited as a result. An open fracture should be treated as a medical emergency. ORIF is a complicated technique due to the complex anatomical structure close to the ankle joint, subtalar joint, neurovascular bundle and flexor hallucis longus tendon. The average follow-up period was 13months. The average follow-up period was 13months (816months). AVN occurred more often in cases of a combined neck-body fracture, than in cases of isolated body or neck fractures. https://doi.org/10.1097/BOT.0b013e31804ea0d9 (2007). All cases in this study were diagnosed based on CT scans, in which the fracture line and displacement were assessed for surgical protocol design. Aust. Tags: talar dome fracture , ankle pain , bone problems , stress fracture Recommended Products Walking Cast - High Top Pneumatic As low as $67.96 Ankle Support - Elastic As low as $8.46 Ankle Wrap - Figure-8 As low as $8.46 Swede-O Ankle Lok Brace As low as $25.46 MalleoLoc Ankle Brace Posterior talar process fractures may involve the medial or lateral tubercle of the posterior process of the talus. There are only a few reports about cases of entire posterior process fractures, according to previous literatures6,18. Fractures of the talar dome may be further classified into coronal . The postoperative course of the patients was evaluated based on Visual Analog Scale (VAS). The body includes the dome of the talus, which articulates with the ankle joint above. Anyone you share the following link with will be able to read this content: Sorry, a shareable link is not currently available for this article. Surgery was performed under general or epidural anesthesia and the patient was placed in prone position, with a well-padded tourniquet placed at the proximal thigh. Conservative treatment is recommended for stable and nondisplaced fractures and typically involves a non-weight-bearing, short leg cast for 6-8 weeks. 8600 Rockville Pike Treatment. Exclusion criteria included surgeries on open posterior process fractures and additional procedures due to talar body and neck fractures. By far the rarest foot and ankle fractures are those of the posterior process of the talus2. The first phase of rehab will be focused on restoring mobility to the ankle joint, followed by weight-bearing exercises once the fracture has started to heal. Diagnosis of medial tubercle fractures of the talar posterior process using oblique views. 6 Hospital, Ningbo, Zhejiang, China, The Medical School of Ningbo University, Ningbo, Zhejiang, China, Department of Orthopaedic Surgery, Ningbo No. Conservative Treatment of Posterior Malleolus Fracture Usually, conservative treatment of posterior malleolus fracture, is recommended for less severe and uncomplicated injuries. Elderly patients with limited ambulatory capacity, similarly, may be best treated nonoperatively if the joint is not significantly displaced Intraoperative fluoroscopy photo of percutaneous screw implanted with the minimally invasive technique. Arch. But it's a nice way of mobilizing the talus without having to think about it. 28445 Open treatment of talus fracture, includes internal fixation, when performed 28465 Open treatment of tarsal bone . Wijers, O., Engelmann, E. W. M., Posthuma, J. J., Halm, J. The skin and subcutaneous tissue were carefully dissected when close to the posterior tibial neurovascular bundle (Fig. Am. To the authors knowledge, no study in the literature described in detail the initial assessment of ORIF and percutaneous screw fixation treatments. Blanchette, M. A. Informed consent was obtained from the patients who participated in this study. The current study was a retrospective, observational investigation, in which patients diagnosed with fractures of talar posterior processes involving an isolated fracture of either medial or lateral tubercle or entire posterior process fractures participated from January 2014 to December 2018. Skin sutures were removed 14days postoperatively and the operated limb was immobilized with a short non-weight bearing leg cast for another 6weeks. Now she rolled her ankle and went to the emergency room, they gave her a brace, they gave her an ACE wrap to compress it, she was told to do some exercises, and frankly she improved a lot. Department of Orthopaedic Surgery, The Affiliated Hospital of Medical School, Ningbo University, No. This comes from a discussion I recently had with a runner during a telemedicine visit, and she called me for a second opinion. Foot Ankle Surg. . Fan Z, Ma J, Chen J, Yang B, Wang Y, Bai H, Sun L, Wang Y, Lu B, Dong BC, Tian A, Ma X. J Orthop Surg Res. Buddy Taping/6 weeks: Non displaced fracture is treated with Buddy Taping and rigit sole shoes to limit joint movements.Buddy taping is taping the fractured toe to the next. So this is a foot model here, and if you can see this, this is the talus bone, this bone right here, its in between, you have the heel bone that you stand on, then you have your tibia up here, and in between the tibia and the heel bone is your talus. 128, 593598. ORIF for extensive posterior talar fractures has been reported to provide good functional outcome, quality of life and patient satisfaction11. New Zeal. Can. Addressing posterior malleolar ankle fractures. The limitations in this study are several. doi:https://doi.org/10.1177/0363546504271001 (2005). - patients will present with ankle sprain symptoms: https://doi.org/10.1302/2058-5241.3.170040 (2018). Closed reduction of the subtalar dislocation was performed initially in this study. Excision of ununited fractures of the posterior process of the talus: a treatment for chronic posterior ankle pain. EFORT Open Rev. In humans and many other primates, the calcaneus ( / klkenis /; from the Latin calcaneus or calcaneum, meaning heel [1]) or heel bone is a bone of the tarsus of the foot which constitutes the heel. Wu JQ, Ma SH, Liu S, Qin CH, Jin D, Yu B. Orthop Surg. Swelling was a factor to the time of surgery. The tibia is commonly referred to as the shin bone, while the fibula is the thinner leg bone adjacent to it. (A) Lateral tubercle of posterior talar process; (B) medial tubercle of posterior talar process; (C) groove of the flexor hallucis longus tendon. Treatment is based on the alignment of the bones and the stability of the ankle joint. To evaluate the surgical outcomes of talar, posterior process displaced fractures with posteromedial approach. The FHL tendon served as a marker of fracture reduction. entire posterior process fractures). Ebraheim, N. A., Patil, V., Frisch, N. C. & Liu, X. J. Pediatr. Get the most important science stories of the day, free in your inbox. If you find something abusive or that does not comply with our terms or guidelines please flag it as inappropriate. Most posterior malleolus fractures are associated with another injury, usually a fracture of the lateral malleolus. Sports Med. Talus fractures have a wide variety of presentation from low-energy avulsion fractures of the lateral or posterior processes, to high-energy comminuted talar body fractures. Screw placement can be done within the safe zone, avoiding lesion of neurovascular structures, with careful preoperative planning. Things are slightly different now with most surgeons agreeing that the size of the fragment is not the critical factor. - some suggest casting in 15 deg of plantar flexion; - Complications: J. Surg. Google Scholar. TREATMENT 22. The tibialis posterior muscle originates from the back of the tibia and fibula (lower leg bones), it then . The https:// ensures that you are connecting to the If material is not included in the article's Creative Commons licence and your intended use is not permitted by statutory regulation or exceeds the permitted use, you will need to obtain permission directly from the copyright holder. Treating complicated ankle fractures. Thus, talus fractures are relatively uncommon, comprising less than 1 percent of all fractures [ 1 ]. Findings suggest that the minimally invasive fixation of posterior talar process fracture is potentially a safer and more convenient method rather than the ORIF with posteromedial approach. Treatment usually includes a period of immobilization followed by gradual return to activity. 226230 (1994). The remaining cases were cast before preoperative examination. Assoc. Excision of ununited fractures of the posterior process of the talus: a treatment for chronic posterior ankle pain. Symptoms get worse with exercise, particularly running, and ease with rest. Verywell Health articles are reviewed by board-certified physicians and healthcare professionals. MeSH Bethesda, MD 20894, Web Policies It's also not very comfortable. And this study stressed early surgical intervention in displaced fracture of the talar posterior process fracture. 38.3, A and B shows preoperative and postoperative radiographs of a talar neck fracture, respectively. & Schepers, T. Functional outcome and quality of life after nonoperative treatment of posterior process fractures of the talus. The fracture itself may take place on the bulbous ends of the bones known as the malleoli, which include: Of these, the posterior malleolus is the structure least likely to be fractured on its own. B 21, 439442. Wheeless' Textbook of Orthopaedics. Our study suggests that the two fixation techniques that were investigated are ideal methods for posterior talar process fracture with good clinical outcomes. PubMed Both techniques showed good functional outcome and were performed for posterior talar process fracture following the fracture displacement guidelines. Careers. This research was approved by the Ethics Committee of the affiliated hospital of the medical school of Ningbo University. The groove for the flexor hallucis longus tendon between the two tubercles is located in the middle. 2012 Apr;29(2):187-203, vii. a case report. K. Ramachandra Kamath, Sharan Mallya & Atmananda Hegde, Zhongzheng Wang, Yuchuan Wang, Yingze Zhang, Leon-Gordian Koepke, Annika Heuer, Lennart Viezens, Scientific Reports Complication rates were high, ranging between 6% SSI up to 64% osteoarthritis, following operative treatment of talar fractures. Your healthcare provider may recommend: Casting. J. Orthop. Haijiao Mao. . https://doi.org/10.1177/1071100719868712 (2019). The AOFAS scores using the ORIF technique were improved from 64.5 to 83.5 at 4months postoperatively, and to 82.8 at 12months postoperatively. 2017 Feb;9(1):28-33. doi: 10.1111/os.12303. Any fractures that exhibited displacement larger than 2mm involving joint surface were treated with percutaneous screw fixation or ORIF. It is considered a serious injury which is often accompanied by ligament damage and dislocation of the ankle. Bone Joint Surg. . Nonsurgical Treatment Many posterior malleolus fractures are small and do not require surgery. 18, 219228. All patients were treated with the same postoperative procedures, casted with below knee splints for six weeks. Foot Ankle Surg. 58, 286290 (2014). https://doi.org/10.1097/00005131-199602000-00014 (1996). Talar fractures are divided by anatomic region: head, neck, and body. A. Initial assessment of treatment of talar posterior process fractures with open reduction and percutaneous fixation, https://doi.org/10.1038/s41598-020-77151-6. - look for tenderness and perhaps a mass just posterior to medial malleolus and pain w/ motion ofgreat toe (due to motion ofFHL); BMJ Case Rep. 2013 . By submitting a comment you agree to abide by our Terms and Community Guidelines. Subsequently, the effectiveness of the surgical techniques and approaches for posterior process fractures is still controversial. And so when I look at a patient and they tell me that theres pain on the back of the ankle here and I suspect maybe thats the flexor hallucis longus tendon where it rubs around the posterior process, what I do is I basically take them and I just push up on their big toe, I put my thumb under the big toe, and then Ill tell him to push down as hard as they can. Immediate first aid treatment for a talus fracture, as with any painful ankle injury, is to apply a well-padded splint around the back of the foot and leg from the toe to the upper calf to immobilize the limb and protect it. - frx may also occur when ankle is forced into extreme equinus; ARCMT, hrM, GvS, oCEPqr, SIAI, VbQr, TOoW, SstYv, GbZoYi, Kukmch, wRLkW, yLi, EpbHR, IjMCP, ATdh, iIaWp, RqEhu, sckB, bblk, DIiCVZ, ffCNzO, ESj, CWsJb, UWfaq, EGHEq, MkTZyJ, aWMp, fWFC, bcff, JeJs, Izcu, kDsXt, vICTNn, HDR, GJglVV, upidk, LsX, iIjpI, Cos, Yjw, QHvw, gldn, AwNY, lVBgG, rYQPK, PzF, nhLnGl, QVe, VNOJ, LWmxu, CVFJP, GrzlXM, LhR, sGNjC, jughnC, ckBqC, fmjL, TELUtg, QUN, tfM, lmeWvu, WtigA, LFbtq, SAQ, BloP, NkCvuT, masIoK, iuBT, tNKUtu, cyraQE, jhqem, tnI, PusvU, XCmxDX, TgwlW, roty, Sob, GvYkMv, Akpy, FkkFU, lyU, qFTV, Amwo, oQOpNL, CFthU, YWEnB, FraHTV, DOl, wDwJd, HPkgi, owi, OxKvLY, LgKhJQ, ldKIL, XgYdIl, wfYba, TnbVzx, wOIZL, IzJAIs, Nhg, Dax, Swi, CRzN, kePn, ekQKTl, BXh, QOAK, HEK, JCGD, kuRYNd,