Asymptomatic os trigonum rarely requires treatment. Cases that have shown the presence of an os trigonum are usually those in which foot symptoms other than static errors are pronounced. The os trigonum is an inconsistently present accessory bone of the foot situated at the posterolateral aspect of the talus. Jul 22, 2010 an os trigonum is one of the bony ossicles of the foot and can be mistaken for a fracture. The separate piece of bone is called an os trigonum. It appears between the ages of eight and 11 years as a nucleus of secondary ossification that generally fuses in less than one year. A radiologists guide to timely diagnosis and classification1 the talus, the second largest tarsal bone, has distinctive imaging characteristics and injury patterns.
A direct impact trauma mechanism or highenergy trauma leads to simple shaft fractures with related extensive soft tissue damage. Accessory ossicles accessory ossicles are secondary ossification centers that remain separate from the adjacent bone. The os trigonum fracture related to the first case was sustained following a hyperplantar flexion injury during a game of soccer. Hyperplantarflexion of the ankle is the mechanism of injury in which the os trigonum is compressed between the posterior malleolus of the tibia and the tuber calcaneus. However, reports of post operative management for os peroneum are limited. Ostrigonumsyndromesurgery foot surgery whatwetreat.
The combination of ipsilateral femoral shaft and tibial shaft fractures, producing a floating knee, signals a high risk of multisystem injury in the patient. Arthroscopy pics of os trigonum attached by cartilage. Os trigonum syndrome is a subset of posterior ankle impingement caused by. A high index of suspicion is necessary to diagnose a fracture of the os trigonum after a severe plantarflexion injury to the ankle. Computed tomography is the choice of imaging modality in cases where fractures of posterior talus structures, including the. The os trigonum is one of the largest and most common accessory ossicles in the ankle and foot region, located posterior to the lateral tubercle of posterior process of talus, with an estimated prevalence of 125%. An xray will show a small, accessory bone with smooth edges distinguishes it from a fracture of the talus. In both cases, a preliminary diagnosis of a posterior talar process fracture was made from the initial radiographs of the ankle. Occasionally, abnormal structures such as an os trigonum can increase the risk of developing symptoms of posterior ankle impingement.
Symptomatic os trigonum in national level javelin thrower. Pdf the operative management of os trigonum syndrome in. The os trigonum or accessory talus represents a failure of fusion of the lateral tubercle of the posterior process of the talus bone. Feb 17, 2011 treatments for an os peroneum fracture include nonoperative management, fixation of the fracture, excision of the bone with direct repair of the tendon, and tenodesis of the peroneus longus to the peroneus brevis 7, 9, 10, 15, 18, 2023, 27, 29, 30. The os trigonum syndrome can be caused by overuse or trauma. Os trigonum surgery is used to remove a painful ostrigonum small bone at the back of the foot. Also known as ankle impingement, posterior impingement syndrome, posterior impingement of the ankle, os trigonum syndrome what is posterior ankle impingement. This separation of the os trigonum from the talus is usually not a fracture. One would perform surgery with the patient under the anesthesia of choice.
The physiopathology of os trigonum syndrome calls into question an exaggerated plantar flexion that is either acute this is the equivalent of a fracture of the. We report a case of a fracture of the os trigonum, its clinical features, treatment and significance. Ankle impingement is a syndrome that encompasses a wide range of anterior and posterior joint pathology involving both osseous and soft tissue abnormalities. Surgical management is recommended if nonoper ative treatment fail. The os trigonum syndrome refers to pain posterior of the ankle and reduced plantarflexion caused by the nutcrackerphenomenon. Treatments for an os peroneum fracture include nonoperative management, fixation of the fracture, excision of the bone with direct repair of the tendon, and tenodesis of the peroneus longus to the peroneus brevis 7, 9, 10, 15, 18, 2023, 27, 29, 30. It may be difficult both clinically and radiographically to distinguish an acute fracture of the os trigonum from a fracture of the posterior talar process. The presence of an os trigonum isnt sufficient to create the syndrome. A rare case of symptomatic os supranaviculare in a sportsman. This commonly affects dancers, especially those assuming the extreme plantarflexed position that pointe work requires. In all patients, mr imaging demonstrated abnormal bone marrow signal intensity in the os trigonum andor lateral talar tubercle, consistent with bone contusions. Mri is useful to show the bone marrow swelling of the talus andor os trigonum.
Os trigonum syndrome is the most common cause of posterior ankle impingement. Endoscopic os trigonum excision through a posterior approach. The primary presenting feature of os trigonum is the presence of pain and stiffness in the ankle which tends to get worse with any movement. It may be radiographically confused with fractures of the posterior process of the talus. If nonsurgical treatment doesnt provide pain relief, a foot and ankle specialist may. Endoscopic versus open excision of os trigonum for the treatment of posterior ankle impingement syndrome in an athletic population.
Management of foot pain associated with accessory bones. Posterior impingement and os trigonum springerlink. Usually, the ossicle fuses to the talus, forming the posterolateral process of the. Surgical treatment of the symptomatic os trigonum in children em. Thus, the presence of this fracture in an acute setting should prompt a search for other associated fractures. The full text of this article is available in pdf format. Diagnosis of os trigonum syndrome begins with a thorough history and examination of the foot and ankle. The correct diagnosis of an os trigonum fracture rather than a fracture of the posterior talar process could only be made following assessment with ct imaging. In reporting these two cases, it may be well to understand that an os trigonum occurs more frequently than is recognized and that its fracture is not unusual. An os trigonum sometimes causes problems of impingement in the back of the ankle. Posterior ankle impingement is a condition characterised by tissue damage at the back of the ankle joint due to compression of these tissues during maximal ankle plantarflexion figure 2. Impingement related to the trigonal process can result from acute fracture, chronic injury due to repetitive microtrauma, or. The os trigonum is an accessory bone located at the posterolateral aspect of the talus in approximately 5% to 10% of the global population. Pdf on jun 28, 2019, karim mahmoud and others published the operative management of os trigonum syndrome in dancers through a.
After the foot and ankle are examined, xrays or other imaging tests are often ordered to assist in making the diagnosis. Muscles allowed other causes of pain in the back of the ankle including small avulsion fractures off of the tibia or fibula or fractures of the body of the talus. Known risk factors for the development of navicular stress fractures include pes cavus, metatarsus adductus, limited subtalar or ankle motion, medial narrowing of the talonavicular joint, as well as a short first metatarsal. Usually, the ossicle fuses to the talus, forming the posterolateral process of the talus or steidas process. The predominantly extraosseous vascular supply of the talus predisposes it to significant injury in the setting of trauma. The os trigonum syndrome refers to symptoms produced by pathology of the lateral tubercle of the posterior talar process. A trial of conservative treatment with a shortleg cast and physical therapy failed to relieve the pain. Imaging revealed an acute fracture of the os trigonum in addition to multiple, other lowerextremity fractures. Athletes may also experience os trigonum syndrome due to pushoff maneuvers i. Main trauma mechanism for femoral shaft fractures is a direct fall on the affected limb 37. Os trigonum of the talus usually refers to an accessory bone that is not. Podiatry management is the national practice management and business magazine, reaching over 18,440 subscribers. However, in the case of symptomatic os trigonum, especially when the pain arises from an ankle injury, it can be difficult sometimes to discern between os trigonum and a fracture of the posterolateral process of the talus stiedas process. The overall prognosis of os trigonum syndrome after this type of treatment is usually excellent with complete resolution of symptoms and return to activities of daily living and sports related activities within six to eight weeks post surgery for os.
Pdf the os trigonum is an inconsistently present accessory bone of the foot situated at the posterolateral aspect of the talus. Introduction the heel bone of horse was used as dice and was called taxillus. Diagnosis of os trigonum syndrome begins with questions from the doctor. A patient with an os trigonum fracture typically has chronic ankle pain or chronic ankle pain that does not completely resolve. Pain can be caused by disruption of the cartilaginous synchondrosis between the os trigonum and the lateral talar tubercle as a result of repetitive microtrauma and chronic inflammation. Os trigonum syndrome os trigonum syndrome, common in ballet dancers, can sometimes be treated nonsurgically using conservative techniques, such as modifying activities and using the rest, ice, compression and elevation r.
Os trigonum syndrome is the result of an overuse injury of the posterior ankle caused by repetitive plantar flexion stress. Her symptoms returned with ballet activity following a 1 month course of full rest, nonsteroidal antiinflammatory medication, and physical therapy. Management of foot pain associated with accessory bones of. Careful physical examination and correlation with radiographic findings may be necessary to differentiate a fracture of the lateral tubercle, a fracture of a fused os trigonum, a tear in the. Radiological studies reported the prevalence of os trigonum between 2. The chondroosseous border of the synchondrosis may be injured either as a chronic stress fracture or, less frequently, as an acute fracture, comparable. Eleven patients were retrospectively evaluated after removal of the os trigonum after a mean followup of 35 months. Talus fracture other than neck trauma orthobullets. Symptomatic os trigonum is a rare condition, well described in adults, that causes chronic ankle pain. Treatment can be medical at first, but should not delay surgical management if it is not successful.
Open fx management adult knee trauma radiographic evaluation. Two patients had a fragmented os trigonum or lateral tubercle, and two had a pseudoarthrosis of the posterolateral talus. If you believe the os trigonum is an accessory bone to the talus, you would code the fracture closed as icd9 825. The purpose of this case report is to describe the postoperative management and returntodance progression of an adolescent dancer post os trigonum excision. The extra small bone in the back of the ankle called the os trigonum. Os trigonum results from a secondary ossification center, thought to develop between 7 years old. Not many people have this extra bone, and many of those who do dont k. The os trigonum may be considered a developmental analogue of a secondary ossification center similar to the posterior calcaneal apophysis although there are obvious histologic differences. Diagnosis of os trigonum syndrome begins with questions from the doctor about the development of symptoms.
Os trigonum syndrome usually involves young and athletic adults. There are three main goals for treatment of os trigonum. Os trigonum syndrome occurs due to repetitive, forceful plantarflexion or pointing. Os trigonum may develop as a separate bone adjacent to the lateral tubercle of the posterior process of talus, having a fibrous, fibrocartilaginous or cartilaginous articulation, or it may fuse becoming a part of the posterior process of talus 1. During routine dissection in a male cadaver os trigonum was. Nonoperative treatment of an os peroneum fracture in a. In this case, the fracture of the os trigonum was a result of a significant traumatic injury.
Timing of fracture stabilization is depended on the overall medical condition of the patient, but definite fracture fixation can often be implemented in the early total care. Symptomatic os supranaviculare case reports are rare in literature and therefore may be considered in the differential diagnosis of dorsal foot. Os trigonum as one of the most common accessory ossicles of foot, may have a fibrocartilaginous articulation with posterior process of talus. Open excision of a painful os trigonum can be associated with prolonged recovery. The os trigonum is an accessory bone of the foot found in 7% of the normal adult population. Despite well known chronic injuries of athletes, acute fracture of the os trigonum.
It sits posterior to the talus on the lateral foot radiograph and represents a failure of fusion of the lateral tubercle of the posterior process. Apr, 2011 tarsal navicular stress fractures are injuries more commonly observed in athletes involved in sprinting and jumping sports. Rotational or wedge type shaft fractures are due to an indirect trauma mechanism with minor soft tissue damage. This articulation may be misdiagnosed as a fracture of. Surgical management of the symptomatic os trigonum and the fractured posterolateral process of the talus involves the same surgical procedure. It is predominantly seen in ballet dancers and soccer players and is primarily a clinical diagnosis of exacerbated posterior ankle pain while dancing on pointe or demipointe or while doing pushoff maneuvers.
Nonoperative treatment of an os peroneum fracture in a high. Posterior impingement surgery os trigonum royal orthopaedic. Os trigonum syndrome can mimic other conditions such as an achilles tendon injury, ankle sprain, or talus fracture. To confirm the diagnosis, xrays or mri are usually ordered. In high velocity injuries ipsilateral hip dislocation and acetabular fractures have to be excluded. The image below is that of an intraoperative image under arthroscopy of a symptomatic os trigonum indicated by metal probe. Endoscopic excision of the os trigonum is a safe and effective treatment option for athletes who require early return to their previous sports level.
The correct diagnosis of an os trigonum fracture rather than a fracture of the posterior talar process was only made following further assessment with ct imaging. Os trigonum syndrome can mimic other conditions, such as an achilles tendon injury, ankle sprain or talus fracture. Endoscopic versus open excision of os trigonum for the. The anatomical relations are complex and any distortion is magnified in gravity by the importance of the reciprocal articulations. Surgical treatment of the symptomatic os trigonum in. Ankle impingement journal of orthopaedic surgery and. We report three patients, one with acute fracture and two with chronic ankle symptoms. Ce diagnostic doit etre evoque chez les patients presentant une. This word evolved into talus in 1919, anderson published a series of foot injuries sustained by aviators in world war i which he called aviators astralagus. The os supranaviculare and navicular stress fractures. Ice is applied for 20minute periods 34 times per day.
Modified brostromgouldevans lateral ankle repair 34. The image below is after removal of the os trigonum and now you can clearly visualize the posterior facet of the subtalar joint with healthy cartilage. A large bone fragment posterior to talus following medial. When an os trigonum is present, this accessory ossicle together with surrounding soft tissues can become wedged between the tibia, talus and calcaneus. A plantarflexion inversion sprain is the prime mechanism for acute fracture of the os trigonum, accounting for nearly 85% of cases. This articulation may be misdiagnosed as a fracture of the posterior process of talus. Foot fractures that are frequently misdiagnosed as ankle. In some people the lateral tuberosity is not united to the talus. By scott pensivy, pt, lat, atc august 2019 contents. Dpl,t introduction the os trigonum is an anatomical variant of the posterior process of the talus where a secondary center of ossification located within the lateral tubercle fails to fuse with the main body of the talus.
The second case involved a patient who fell from height and also sustained open fractures of the left distal tibia and lateral malleolus as well as the right calcaneus. However, complication rates were remarkably lower with endoscopic treatment, and the time to return to full activities was much shorter. Os trigonum fracture in the differential when ankle trauma continues to demonstrate pain for longer than the typical healing time after the might be an issue, and other pathologies need to be consideredin particular, fracture of the os trigonum. Diagnosis of os trigonum syndrome begins with questions from the doctor about the development of the symptoms. Hence management of femoral shaft fractures is often directed by comorbidities, additional injuries and the medical condition of the patient. It was, therefore, decided to excise the ununited fragment. Following excision of an os trigonum, it is important to have a gradual, progressive returntodance program for optimal recovery. Structurally, the os calcis, by reason of the absence of a shaft and because of its spheroidal shape, offers very evident restrictions to manipulation and immobilization. An arthroscopic technique has been developed to decrease scarring, diminish surgical morbidity, and promote a faster recovery. Mri was used as a problem solving tool and should be used in concert with clinical findings to guide proper management. The ostrigonum is an accessory extra bone that sometimes develops behind the talus ankle bone during adolescence. An os trigonum may represent failure of fusion of a secondary ossification center to the talar body, although this structure has been heavily debated in the orthopedic and radiologic literature. Conservative management of posterior ankle impingement.
Once the os trigonum has been identified as the cause of symptoms, treatment can include nonsurgical management with rest and immobilization of the ankle, including the use of a special boot or splint to provide support to the joint while inflammation. Os trigonum syndrome is a painful, relatively uncommon condition that results from compression of a congenital bony anomaly an os trigonum, found at the posterolateral aspect of the talus and nearby soft tissue in the posterior tibiocalcaneal interval. Surgical treatment of the symptomatic os trigonum in children. The os trigonum is an accessory bone with inconstant presence at the posterolateral side of the talus.