Bilateral Cedell Fractures of the Talus Associated with Ankle Fractures in a Polytrauma Patient: A Rare Injury Managed with Damage Control Orthopedics and Staged Fixation

Management

A staged DCO approach was adopted.

Stage 1 addressed the most urgent injuries. Posterior spinal instrumentation from L2 to L4 was performed for the L3 bony Chance fracture, achieving restoration of spinal alignment, as the injury was a purely osseous flexion-distraction lesion without neurological compromise or significant anterior comminution (Fig. 3a and b). Surgical fixation of the right medial malleolus fracture through anteromedial approach interval was created through the fracture and marginal impaction was corrected and cancellous bone from distal tibia was used as local bone graft . Provisional fixation was achieved with a Kirschner wire, placed subchondral. The anterior plafond rim also was fixed using an anterior-to-posterior screw using cancellous screws, supplemented by temporary ankle-spanning external fixation for the associated fracture-dislocation of the ankle (Fig. 3c and d).

Stage 2 was performed 1 week after the initial surgery, following physiological optimization and recovery of the soft tissues around the ankle after 1 week. The patient was positioned prone with an ipsilateral thigh tourniquet. Both the right and left talar fractures were addressed through a posteromedial approach using an incision just medial to the Achilles tendon. The FHL tendon was identified and retracted medially to expose the posteromedial talus, as described by Swords et al. ^[4]. Careful handling of the FHL was ensured throughout the procedure to minimize the risk of post-operative Checkrein deformity ^[5]. The right talar fracture was fixed with three 4-mm Herbert screws through a posterior-to-anterior trajectory, with care taken to avoid subtalar joint penetration (Fig. 4a and b). The left talar fracture was fixed with a single 4-mm headless compression screw through the same trajectory. The left pilon fracture was addressed through an anteromedial approach, providing direct access to the anterior plafond and central articular impaction. The anterior cortical fragment was opened, the impacted articular surface anatomically reduced, supported with local cancellous bone graft, temporarily stabilized using subchondral Kirschner wires, and fixed with an anterior buttress recon locking plate ^[6]. (Fig. 4c and d show the left ankle’s headless compression screw fixation of the talar fracture together with plate and screw fixation of the tibial plafond) (Fig. 4c and d) ^[6]. The approach was selected based on the fracture morphology demonstrated on preoperative CT imaging ^[7].

At follow-up, the left ankle united uneventfully with full range of motion. The patient developed persistent right hindfoot pain during weight-bearing. CT demonstrated post-traumatic subtalar arthritis with one Herbert screw breaching the subtalar joint. As the pain was attributed to both the initial articular injury and screw penetration, the screw was removed. The subtalar arthrodesis through the sinus tarsi approach with an incision from the lower end of the fibula to the fourth metatarsal base, and through the same approach, transosseous lateral ligament repair was performed. The subtalar joint was fixed with 2 partially threaded 6.5 cannulated cancellous screws. The patient went on to do well, with his subtalar pain relieved and ankle plantar and dorsiflexion was preserved.

Results

Post-operative course was uneventful, with satisfactory wound healing and no early wound-related complications. Postoperatively, both lower limbs were immobilized in a below-knee splint with strict non-weight-bearing for 6 weeks. Progressive ankle range-of-motion exercises were initiated after soft-tissue healing, followed by gradual weight-bearing based on clinical and radiographic evidence of fracture union. At 6 months, radiographs demonstrated complete union of the bilateral posteromedial talar process fractures and associated fractures (Fig. 5). During subsequent follow-up, the patient developed persistent right subtalar pain due to post-traumatic subtalar arthritis, managed as described above with revision fixation and subtalar arthrodesis (Fig. 6). At the 1-year follow-up, radiographs demonstrated complete union of the bilateral distal tibial and posteromedial talar process fractures with maintained reduction, stable implant position, restoration of the ankle mortise, preserved tibiotalar joint congruity, successful right subtalar arthrodesis, and no evidence of implant loosening or talar avascular necrosis (AVN)(Fig. 7). At the 1-year follow-up, the patient was pain-free, had preserved ankle dorsiflexion and plantarflexion bilaterally, intact FHL function, and was able to perform toe-standing and a single-leg heel rise. He returned to his pre-injury functional level with satisfactory hindfoot stability and an American Orthopaedic Foot and Ankle Society ankle-hindfoot score of 95 (Fig. 8).

Discussion

Cedell fractures remain a diagnostically challenging subset of talar injuries. Their mechanism – forced dorsiflexion and pronation generating avulsion at the posterior talotibial ligament – differs from the axial compression mechanisms underlying most talar body fractures ^[2]. In polytrauma, distracting injuries compound the risk of missed diagnosis; CT should be strongly considered when clinical suspicion persists despite inconclusive radiographs.

Displaced fractures with subtalar joint involvement are best managed operatively. A systematic review by Engelmann et al. reported superior functional outcomes following open reduction and internal fixation compared with non-operative treatment (33.3% vs. 64.7% impaired outcomes), supporting surgical fixation for displaced posterior process fractures ^[3]. Similarly, Zwiers et al. reported fragment excision as a reasonable alternative for small, comminuted, or chronic symptomatic fragments not amenable to stable fixation ^[8]. Long-term complications including subtalar arthritis and AVN require extended surveillance; although no AVN was detected at 6 months, late AVN may occur up to 2 years after injury, given the talus’s tenuous retrograde blood supply ^[9].

The posteromedial approach between the neurovascular bundle and FHL tendon provided excellent exposure while protecting critical structures [4, 10]. Headless compression screws through a posterior-to-anterior trajectory afforded stable fixation with minimal hardware prominence.

The staged DCO strategy was critical in this case. Temporizing the ankle with external fixation while addressing the spinal injury in Stage 1 allowed soft-tissue recovery and patient optimization before Stage 2 definitive hindfoot and pilon surgery, contributing to the favorable outcome.

Although the patient was hemodynamically stable, a staged DCO strategy was chosen due to the associated spinal injury, marked peri-ankle soft-tissue swelling, and the anticipated prolonged operative time for bilateral definitive fixation. Temporary stabilisation permitted soft-tissue recovery before definitive reconstruction 1 week later.

Previous reports have demonstrated satisfactory outcomes following operative treatment of isolated posteromedial talar process fractures; however, bilateral Cedell fractures remain exceedingly uncommon, making the present case a valuable addition to the existing literature [11, 12].

Limitations include short-term follow-up and the absence of additional patient-reported functional assessment tools such as the Manchester-Oxford Foot Questionnaire. Patient remains under continued follow-up surveillance for late complications including AVN and subtalar arthritis.

Conclusion

Bilateral Cedell fractures in polytrauma are exceptionally uncommon and can be easily overlooked. Careful clinical assessment, early CT imaging, and staged fixation based on DCO principles can provide excellent functional and radiological outcomes. Early anatomical reduction and stable fixation of displaced fragments minimise the risk of non-union, subtalar arthritis and FHL dysfunction. Even when a secondary procedure like subtalar arthrodesis becomes necessary, staged fixation followed by targeted salvage can still restore excellent hindfoot function.

Clinical Message

Posteromedial talar process (Cedell) fractures should be actively sought with computed tomography imaging in high-energy polytrauma, as they are easily missed on plain radiographs; even when subtalar arthritis develops post-fixation, staged damage control orthopedic management followed by targeted salvage procedures such as subtalar arthrodesis can still achieve a functionally excellent outcome.

Conflict of Interest:

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Consent:

The authors confirm that informed consent was obtained from the patient for publication of this article

How to Cite this Article

Sivakumar S, Pattabiraman K, Salam N, Chereykkatt N, Dwajan A, Patel S. Bilateral Cedell Fractures of the Talus Associated with Ankle Fractures in a Polytrauma Patient: A Rare Injury Managed with Damage Control Orthopedics and Staged Fixation. Journal of Orthopaedic Case Reports 2026 October;16(10): 264-269.