Accepted Manuscript

Title: Fractures of the talus: Current concepts and new

developments

Authors: John A. Buza III MD, MS, Philipp Leucht MD, PhD

PII: S1268-7731(17)30086-3
DOI: http://dx.doi.org/doi:10.1016/j.fas.2017.04.008
Reference: FAS 1045

To appear in: Foot and Ankle Surgery

Received date: 6-1-2017

Revised date: 9-4-2017
Accepted date: 14-4-2017

Please cite this article as: Buza John A, Leucht Philipp.Fractures of the
talus: Current concepts and new developments.Foot and Ankle Surgery
http://dx.doi.org/10.1016/j.fas.2017.04.008

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Fractures of the talus: Current concepts and new
developments

John A. Buza III, MD, MS, Philipp Leucht, MD, PhD

1
NYU Langone Medical Center, Hospital for Joint Diseases, 301 E. 17th St., New York,

NY 10003

Corresponding Author:

Philipp Leucht, MD, PhD

Assistant Professor, Departments of Orthopaedic Surgery and Cell Biology
NYU Langone Medical Center, Hospital for Joint Diseases
301 E. 17th St, Suite 1500
New York, NY 10003
Philipp.Leucht@nyumc.org
P (646) 501-0291
F (646) 754-9825

Highlights:
 Fractures of the talus are challenging to manage with a high rate of complications
 Advanced imaging with CT scan is recommended in all talar neck fractures
 The Hawkin’s classification system predicts the rate of osteonecrosis
 Dual anteromedial and anterolateral surgical approaches may be beneficial
 Plate fixation often allows for precise reduction with decreased malalignment

ABSTRACT

Fractures of the talus are challenging to manage, with historically poor outcomes and a
high rate of complications. The rare nature of this injury limits the number of studies
available to guide treatment. Fortunately, a number of advancements have been made in
the last decade. There is increased recognition regarding the importance of anatomic
reconstruction of the osseous injury. Advanced imaging is used to assess the subtalar
joint, where even slight displacement may predispose to arthritis. Increasing use of dual
anteromedial and anterolateral approaches, along with plate fixation, has improved our
ability to accurately restore the anatomy of the talus. Modification of the original
Hawkins classification can both guide treatment and allow us to better predict which
patients will develop avascular necrosis. Lastly, improved reconstructive techniques help
address the most common complications after talus fracture, including arthritis, avascular
necrosis, and malunion.
KEYWORDS: talus; fracture; Hawkins; osteonecrosis; post-traumatic arthritis

1. INTRODUCTION

Fractures of the talus are uncommon, and typically occur after high-energy mechanisms
such as a fall from a height or motor vehicle crash. While previous studies cite an
incidence ranging from 0.1 – 2.5% of all fractures, the true incidence is not known.[1, 2]
The infrequency of these injuries is in part responsible for the historically poor outcomes
and high rate of complications, as there was little data to guide treatment. The majority of
previous studies have been small case series, which has further limited our understanding
of the proper treatment of these injuries.
Fortunately, a number of advancements in our understanding of the treatment of
talus fractures has improved outcomes and reduced complication rates. In the past
decade, there have been improvements in the surgical techniques, timing, and
instrumentation of talus fractures. These fractures are classified based on their primary
fracture line into head, neck, body, or lateral/posterior process fractures. These fractures
types have unique anatomy, presentation, and treatment, and will therefore be discussed
separately.

2. RELEVANT ANATOMY

The talus is unique in that over one half of its surface is covered by articular cartilage,
and it has no muscular attachments. (Figure 1) The trochlea, or superior surface,
articulates with the tibial plafond and is wider anteriorly such that maximal articular
congruence of the ankle occurs in dorsiflexion. This superior articular surface extends
both medially and laterally to articulate with the malleoli. The inferior aspect of the talus
is predominantly covered with cartilage, and has posterior, middle, and anterior facets,
which correspond to the articular facets of the calcaneus. The lateral process of the talus
is completely covered by cartilage and articulates with the distal end of the fibula
superiorly and the posterior facet of the calcaneus inferiorly. The posterior process of the
talus is composed of both posteromedial and posterolateral tubercles, which form a
groove that contains the flexor hallucis longus tendon.
The neck of the talus is angled medially at a mean of 24 degrees (range, 10-44
degrees) and plantarly between 5 and 50 degrees.[3] Importantly, the neck is relatively
devoid of articular cartilage and serves as a site of vascular inflow, particularly at the
dorsal neck where capsular and ligamentous attachments originate.
2.1 BLOOD SUPPLY
The talus has a rich network of extra- and intraosseous anastomoses that is
vulnerable to disruption from trauma. (Figure 2) The extraosseous blood supply of the
talus comes from three arteries including the anterior tibial, posterior tibial, and
perforating peroneal artery.[4] The talar head is supplied by branches of the dorsalis pedis
artery and the artery of the tarsal sinus.
Early anatomical studies demonstrated that the main blood supply to the talar
body is through an anastomotic sling located inferior to the talar neck in the tarsal canal.
This sling is composed of the artery of the tarsal canal, which is a branch of the posterior
tibial artery, and the artery of the tarsal sinus, which is a branch of the perforating
peroneal artery.[5] This implied that the majority of the blood supply to the talus was
through retrograde flow, which explained the high rate of AVN in talar neck fractures
after disruption of this sling. A recent study using gadolinium-enhanced MRI found that
the greatest blood supply to the talus enters posteriorly from the posterior tibial artery,
contrasting earlier studies.[6] This finding, the authors concluded, might explain the low
rates of osteonecrosis following talar neck fracture in the recent literature.[6]

3. TALAR NECK FRACTURES

Fractures of the neck of the talus are the most common, accounting for 50% of all talus
fractures.[7] The mechanism responsible for this injury is unknown, but is often ascribed
to forced dorsiflexion of the foot, which drives the weak trabecular bone of the neck of
the talus against the stronger anterior tibial plafond. With increasing dorsiflexion forces,
disruption of the interosseous talocalcaneal ligament and posterior tibiotalar joint capsule
leads to subluxation or complete dislocation of the talus. The talus will often rotate about
the intact deltoid ligament and come to rest between the posterior aspect of the medial
malleolus and the Achilles tendon, where neurovascular structures may be compromised.
In extreme cases, the deltoid ligament may rupture, leading to talar extrusion. Twenty
percent of talus fractures are open, and the rate of associated fractures is as high as 64%,
including the foot, ankle, and spine.[8] In approximately 25% of these fractures,
supination of the hindfoot leads to medial neck comminution and medial malleolus
fracture.[8]

3.1 CLASSIFICATION
The most commonly used classification system for talar neck fractures was originally
described by Hawkins and later modified by Canale and Kelly.[8, 9] (Figure 3) There are
four types which are classified based on the radiographic appearance at the time of injury.
Type I fractures are nondisplaced, with congruent ankle and subtalar joints. (Figure 3A)
Even minimal displacement of 1 to 2 mm of the talar neck results in subtle incongruity of
the subtalar joint, and should not be classified as a Type I. These fractures are difficult to
identity on routine radiographs and may require CT for diagnosis. The rate of AVN in
Type I fractures is less than 10%.[8, 9] (Table 1)
Hawkins type II fractures refer to a talar neck fracture with either subluxation or
dislocation of the subtalar joint. (Figure 3B-C) This is the most common type of talar
neck fracture. In their original series, both Hawkins and Canale noted an AVN incidence
of 42 to 50% for type II fractures.[8, 9] Vallier further subdivided the type II
classification into two subtypes; IIA, those with a subluxated subtalar joint (Figure 3B),
and IIB, those with a dislocated subtalar joint.[10] (Figure 3C) In their series of 81 talar
neck fractures, 0 of the 19 (0%) Hawkins type IIA fractures developed osteonecrosis in
contrast to 4 of 16 (25%) Hawkins type IIB fractures. In subtalar dislocations (type IIB)
there is an increased risk of compromise to the remaining blood supply, which may
account for the increased risk of osteonecrosis.
The Hawkins type III fracture is characterized by a fracture of the neck with a
dislocation of the tibiotalar joint in addition to the subtalar joint. (Figure 3D) The body is
typically extruded posteromedially, which places the tibial neurovascular bundle at risk.
Early cohorts had a reported AVN rate approaching 100%[8, 9], with more recent
reviews citing an AVN rate of 44%.[11, 12] (Table 1) Given the degree of displacement,
many of these fractures are open and are irreducible by closed means.
Canale and Kelly added the type IV talar neck fracture to indicate an associated
subluxation or dislocation of the talonavicular joint.[9] (Figure 3E) These fractures are
extremely rare, representing only 4% of talar neck fractures.[11] The reported rate of
AVN among these fractures is 12-48%, but this may not be an accurate estimate given the
low number of reported type IV fractures in the literature.[11, 12]

3.2 CLINICAL EVALUATION

Patients with talar neck fractures typically present after a high-energy injury such as a
motor vehicle crash or fall from a height, and have foot swelling, pain, or deformity. For
high-energy injuries, the patient should undergo a thorough physical examination to
identify associated injuries.[13] When the talus is dislocated, an urgent reduction in the
emergency room is indicated to reduce the risk of osteonecrosis and skin compromise.
Closed reduction is attempted with knee flexion along with plantar flexion and inversion
or eversion. Repeated forceful reduction attempts should be avoided. Irreducible injuries
should be considered an indication of surgical urgency. Open fractures require urgent
irrigation and debridement in the operating room.[14-16] In severe cases of complete or
partial talar extrusion, the extruded bone fragments should be cleaned and saved to
preserve all future surgical reconstruction options.[17]

3.4 RADIOGRAPHIC EVALUATION

Initial radiographic views should include anteroposterior, lateral, and mortise views of
the foot and ankle. While these views will allow assessment of the talar body, talar neck,
and associated processes, they are often inadequate to assess the alignment and degree of
comminution of the talar neck. Canale and Kelly described a view of the talar neck which
is obtained by maximal plantarflexion at the ankle, 15o of eversion, and angling the beam
75o degrees from the horizontal.[9, 18] CT scans are invaluable to assess for
comminution, intra-articular fragments, and congruent reduction of the tibiotalar,
subtalar, and talonavicular joints.

3.5 TREATMENT
The goals of treatment for talar neck fractures are anatomic reduction, restoration of
articular and axial alignment, preservation of motion, and minimization of complications
including AVN, post-traumatic arthritis, malunion, nonunion, and infection.

3.5.1 Non-operative
Non-operative treatment is reserved for truly nondisplaced Hawkins Type I fractures.
Biomechanical studies have demonstrated that as little as 2mm of displacement
significantly alters subtalar contact forces, which may predispose to arthritis.[19] Thus, a
CT scan should be used to assess displacement prior to selecting non-operative treatment.
Treatment consists of non-weight bearing in a cast for 6 weeks or until radiographic
union, which may take up to 12 weeks.

3.5.2 Operative
The current standard of care for all displaced talar neck fractures is operative reduction
and internal fixation. Closed reduction may be difficult, and when possible it is preferable
to proceed directly to operative fixation to avoid multiple unsuccessful reduction
attempts.
3.5.3 Surgical Approaches
There are various surgical approaches to the talar neck. Regardless of approach, it is
imperative that full-thickness flaps are created with no undermining to avoid soft tissue
necrosis. The anteromedial approach to the talus involves making an incision medial to
the anterior tibial tendon.[16] This incision may be extended proximally if a malleolar
osteotomy is required, or in the presence of a medial malleolar fracture that requires
operative fixation. The major disadvantage of this approach is the inability to visualize
the lateral aspect of the talar neck, which is necessary to judge the quality of reduction.
The anterolateral approach is performed with an incision between the tibia and
fibula and in line with the fourth ray, just lateral to the extensor digitorum longus.
(Figure 4) This incision is the distal extension of the Bohler incision, which is the
extensile anterolateral approach to the foot and ankle.[16] When this incision is used in
conjunction with the anteromedial approach, it is important to maintain an adequate skin
bridge to avoid skin necrosis. This approach allows for anatomic reduction of the lateral
talar neck. If needed, an anterolateral fibular osteotomy can be performed for gaining
access to the proximal lateral talus. Often, there is a cortical fragment at the anterolateral
corner of the talar neck near the margin with the lateral process, from which one can base
an anatomic reduction. Dissection of the inferior neck, deltoid ligament, and sinus tarsi
should all be avoided to maintain the vascular supply of the talar neck.
The posterolateral approach involves making an incision just lateral to the
Achilles tendon, and developing the interval between the flexor hallucis longus and
peroneal muscles. This approach can be used to facilitate lag screw fixation, as the screw
trajectory if perpendicular to the fracture line. Care should be taken to avoid injury to the
peroneal artery and saphenous nerve.

3.5.4 Timing of Surgery

Talar neck fractures were long thought to be orthopaedic emergencies, in which
immediate reduction of the talar neck would minimize the incidence of osteonecrosis.[9]
Recent studies have shown that this is not true, and that osteonecrosis may be more
strongly correlated to other factors such as open fracture or comminution of the talar
neck.[14, 20] Increased time between surgery and operative treatment did not increase the
risk of complications or future surgery.[15] Timing of definitive surgery should be based
on injury to the surrounding soft tissues, as the rate of soft tissue complications ranges
between 2% and 10%.[10] Definitive surgery should be deferred until there is adequate
resolution of swelling, which may take up to 2 weeks after injury. It is critically
important to remember that surgery should only be delayed provided that the talar neck is
in a reduced position. All displaced talar neck fractures require urgent reduction in the
emergency room. Irreducible talar neck fractures should be taken to the operating room
for open reduction and internal fixation on an urgent basis.

3.5.5 Percutaneous Fixation

Percutaneous fixation should be reserved for truly nondisplaced fractures, in which
fixation allows for early range of motion compared to casting. In displaced fractures,
percutaneous fixation is indicated in the rare case in which an anatomic reduction can be
performed and there is no significant comminution. Although low rates of osteonecrosis
and malunion have previously been reported using closed reduction with Schanz pins
followed by percutaneous fixation in Hawkins grades II-IV, it is not recommended.[21]
Screw fixation can be placed from posteromedial, posterolateral, or anterior
approaches.[22]

3.5.6 Open Reduction and Internal Fixation

Dual anteromedial and anterolateral surgical approaches allow for full visualization of the
talar neck. A medial malleolar osteotomy may be required to allow access to the talar
body.[16, 23] Provisional reduction of the talar neck and body can be maintained with
Kirschner wire fixation. Aligning the cortical margins without recognizing the degree of
comminution will lead to improper varus and extension. One strategy to prevent this from
occurring is performing an anterolateral exposure, which allows visualization and direct
cortical reduction of the lateral talar neck. In addition, bone grafting of the medial neck
may be required to provide mechanical support.[15] In all cases, subtalar debridement is
critical to ensure that there is no block to reduction or loose fragments.

3.5.7 Screw Fixation

Screw fixation alone was the predominant method of fixation of displaced talar neck
fractures in most early series as well as several recent ones.[7, 14, 15, 22] Screws can be
placed from anterior-to-posterior or posterior-to-anterior. Anterior-to-posterior screws
(one medial and one lateral) are inserted adjacent to the articular surface of the talar head
and directed posteriorly into the body. Anterior-to-posterior screws may interfere with
talonavicular joint function when prominent. For that reason, it is recommended to
countersink the screw head or use headless lag screws with this technique.
 Posterior-to-anterior lag screw fixation has been shown to have superior
biomechanical strength compared to anterior-to-posterior fixation.[24] These screws are
typically placed from a posterolateral approach on either side of the flexor hallucis
groove, and directed anteromedially. Potential disadvantages of posterior-to-anterior
screw fixation include penetration of the subtalar joint, restriction of ankle plantar-flexion
due to screw-head impingement, or injury to the FHL. Again, headless screws may avoid
this risk and are biomechanically equivalent to standard screws.[25] For both anterior-to-
posterior and posterior-to-anterior screw fixation, it is important to remember that the use
of lag screws in the setting of any comminution will lead to malalignment.[15] Position
screws instead of lag screws can also be used to maintain an anatomic reduction on the
medial side and avoid compressing a comminuted fracture into varus.

3.5.8 Screw and Plate Constructs

Plate fixation of talar neck fractures has become more popular in the last decade, and is
the recommended method of fixation by many authors.[2, 26-28] (Figure 5A-E) The
major advantage of plate fixation over screw fixation is the ability to bridge areas of
significant comminution.[26] This allows for a more precise reduction and avoids the
potential risk of malalignment when using lag screw fixation across areas of
comminution.[29] Areas of comminution should be packed with bone graft to provide
structural support.[2, 15] The plate may be placed either medially or laterally depending
on the location of comminution. Multiple studies have demonstrated that there is no
difference in biomechanical strength between screw fixation alone and combination
screw-plate constructs.[29, 30] Loose osteochondral fragments can be secured with mini-
fragment screws with cruciform heads that are seated below the level of the articular
cartilage, and are particularly useful for talar dome fractures.[16]

3.5.9 Postoperative management

With stable fixation, early range of motion is encouraged once all wounds are healed. If
there is concern regarding the integrity of the fixation, or in cases of significant ankle,
subtalar, or talonavicular instability, casting for 6 weeks is recommended. The patient
should remain non-weight-bearing until there is evidence of sufficient healing on
radiographs, typically between 6 weeks and 3 months after injury.

4. TALAR BODY FRACTURES

Fractures of the talar body involve both the tibiotalar and subtalar joints, and have the
highest incidence of arthritis among all talus fractures.[7] The accurate restoration of a
congruent articular surface is therefore important to minimize the risk of this
complication. Up to 50% of talar body fractures are associated with a talar neck
fracture.[20] Radiologic evaluation of talar body fractures should always include a CT
scan, as plain radiographs may underestimate the degree of articular injury.
The treatment of talar body fractures adheres to many of the same principles as
talar neck fixation; any displacement requires surgical management with open reduction
and internal fixation. The surgical approaches for talar neck fractures may be used for
open reduction and internal fixation of the talar body with minifragment or headless
screws.[16] Medial malleolar osteotomy may be required for access to the talar
dome.[23] It is important not to violate the deltoid ligament, which is an important source
of blood supply to the talar body. Bone grafting should be considered when there is
significant impaction of the talar dome.

4.1 Lateral Process Fractures

Fractures of the lateral process are frequently missed on initial plain radiographs, as they
may be subtle and difficult to visualize. This fracture is classically associated with a
snowboarding injury.[31] Lateral process fractures are best seen on ankle mortise and
internal oblique views, but CT scan is usually required to visualize the fracture and
determine whether operative intervention is necessary. Small or nondisplaced lateral
process fractures may be treated with immobilization and a period of non-weight bearing.
Larger fractures and those with more than 2mm of displacement require fixation with lag
screws or a minifragment plate.[32] Using either a posterolateral or anterolateral
approach has been recommended.[2, 27] When lateral process fractures occur in the
setting of a talar neck fracture, it is advised to stabilize the neck before fixing the lateral
process.[2]

4.2 Posterior Process Fractures

Posterior process fractures are best seen on lateral foot radiographs. It may be difficult to
differentiate between a posterior process fracture of the talus and an os trigonum, which
is an ossicle located behind the talus in up to 25% of the population.[33, 34] Os trigonum
are generally round, oval, or triangular and may have a synchondrosis with the
posterolateral talus. If the diagnosis cannot be made on plain radiographs, advanced
imaging with either CT or MRI will allow for differentiation between os trigonum and
posterior process fractures. Small and nondisplaced fractures of the posterior process may
be treated with immobilization and a period of non-weight-bearing. Larger fragments and
those displaced more than 2mm are best treated with open reduction and internal fixation.
The posteromedial approach allows access to the posterior process by utilizing the
interval between the medial border of the Achilles tendon and the posterior edge of the
medial malleolus. After fracture reduction, the fracture is stabilized with mini-fragment
screws. While range of motion exercises may begin as soon as soft tissue swelling has
subsided, it is recommended that patients remain non-weight bearing for 2 months after
surgery.

5. TALAR HEAD FRACTURES

Talar head fractures are rare, accounting for 2.6-10% of all talus fractures.[35] The
natural history of talar head fractures is largely unknown, as only case reports are
published in the literature.[35-40] (Table 2) These injuries are frequently associated with
talonavicular dislocations, but can be easily missed when spontaneous reduction occurs
before presentation. Standard radiographs should be supplemented with CT scan to assess
the degree of articular displacement. Nondisplaced fractures may be treated with cast
immobilization and non-weight bearing for 4-8 weeks after surgery. Ibrahim et al.
recently suggested a treatment algorithm for displaced fractures on the basis of their
systematic review; (1) displaced fractures with >50% talar head involvement or
talonavicular joint instability should undergo open reduction and internal fixation with
immobilization and non-weight bearing for 6-8 weeks postoperatively whereas (2)
displaced fractures with <50% talar head involvement and no instability of the
talonavicular joint may be treated with excision of fracture fragments, closure of the
talonavicular joint capsule, and a period of immobilization and non-weight bearing.[35]
An anteromedial approach to the talar head is most commonly used. Primary fusion of
the talonavicular joint is an option in cases of severe talar head or navicular
comminution, or as a salvage treatment for end-stage talonavicular post-traumatic
arthritis.

6. TALUS FRACTURES IN CHILDREN

Talus fractures in children are extremely rare. Compared to adult fractures, relatively
little is known about the natural history of talus fractures in children, as there are only a
small number of published case series.[41-47] The primary mechanism of injury for talus
fractures in children appears to be dorsiflexion and axial loading, similar to the
mechanism described in adults.[42, 44, 45] As in adults, talar neck fractures in children
are generally classified by the Hawkin’s classification, and follow similar treatment
protocols. Nondisplaced fractures are generally treated non-operatively with cast
immobilization, whereas displaced fractures are treated operatively.[41] The
complications following talus fractures in children are similar to those found in adults,
and include osteonecrosis, post-traumatic arthritis, nonunion, malunion, and
infection.[41] One key difference between talus fractures in children and those in adults
may be the rate of osteonecrosis after nondisplaced fractures.[47] Rammelt et al. found a
rate of 16% of osteonecrosis after nondisplaced fractures, and proposed that this may be
due to a greater susceptibility to circulatory disturbances in the pediatric talus.[47] It is
important to maintain a high index of suspicion for the development of avascular necrosis
following talus fracture in children, including those that are found to be nondisplaced.

7. COMPLICATIONS AND SALVAGE

7.1 Osteonecrosis
The incidence of osteonecrosis after talar neck fracture increases with greater initial
fracture displacement.[8, 12] (Table 1) The most cited rates of osteonecrosis come from
Hawkins classic work, in which he reported an overall osteonecrosis rate of 58%, with
rates of 0%, 42%, and 86% for Hawkins’ types I, II, and III, respectively.[8] Since the
publication of this report in 1970, the standard of care has evolved to include the use of a
more aggressive dual-incision open approach to all fractures.[11, 28] The reported rates
of osteonecrosis have decreased with the evolution of treatment protocols in the past
decade. (Table 3) In a meta-analysis of 26 studies including 980 talar neck fractures,
Dodd et al. found that the overall rate of osteonecrosis was 31.2%; when looking at
studies published after the year 2000, the rate drops to 24.9%.[12] In studies published
after 2000, the authors also found that the rate of osteonecrosis for Hawkins Type II and
Type III were 20.7% and 44.8%, respectively, which is roughly half the rate reported in
Hawkins original series.[12] Osteonecrosis is also seen more commonly in open talus
fractures.[14, 20]
The diagnosis of osteonecrosis is commonly made on plain radiographs at
anywhere from 4 weeks to 6 months after surgery.[8, 9] The radiographic criteria used to
diagnose osteonecrosis are poorly defined, but it is generally indicated by a relative
increase in the density of the talar body relative to adjacent structures. The presence of
subchondral osteopenia at 6-8 weeks after injury, known as the Hawkins sign, is a
reliable indicator that the development of osteonecrosis is unlikely.[48] The Hawkins
sign has recently been shown to have a sensitivity of 100% and a specificity of
57.7%.[49] The converse, however, is not true; an absent Hawkins’ sign does not confirm
the diagnosis of osteonecrosis.[48] In these cases, MRI can be used for the early
diagnosis of osteonecrosis.
Nearly half of all patients with osteonecrosis will undergo revascularization
without collapse of the talar body, which may take up to 2 years following initial
injury.[2, 10, 14, 20] There is no evidence that prolonged non-weight bearing during this
time will help to prevent talar body collapse. It is important to note that many patients
with talar body osteonecrosis are asymptomatic, and therefore the initial treatment is
conservative. If conservative treatment fails and arthritis develops, arthrodesis of the
involved joint is an effective means of eliminating pain. There are a variety of fusion
techniques described in the literature to accomplish these goals.[50, 51] Motion
preserving techniques have also been reported. Harnroongroj et al. recently reported the
outcomes of 33 patients treated with implantation of a talar body prosthesis, 23 of which
were implanted for talar body osteonecrosis.[52] Of the 33 talar body prosthesis, 28 were
still implanted at final follow-up, ranging from 10 to 36 years post-operatively. The
authors concluded that although early failure can occur, talar body prosthesis can provide
satisfactory foot and ankle function at long-term follow up.[52]

7.2 Post-traumatic Arthritis

Subtalar joint arthritis is the most common complication after talar neck fracture,
developing in an average of 49% of patients in a recent meta-analysis of 16 included
studies.[10-12, 14-16] (Table 3) When including only studies with a minimum of 2 year
follow up, the authors found that this rate increased to 81%.[12] This complication is
even more common after talar body fractures, where the reported rate is as high as
100%.[7, 14, 16] Post-traumatic arthritis may be treated conservatively with bracing and
pain medication. End-stage arthritis recalcitrant to conservative treatment may require
tibiotalar or subtalar arthrodesis for pain relief.[50, 51]

7.3 Malunion and Nonunion

The rate of malunion after talar neck fracture is frequently reported in the range of 20-
30%, but is likely underestimated given the difficulty of identifying malignment by plain
radiography alone.[14, 15, 53] (Table 3) Varus malunion is the most common deformity
due to medial comminution. The dual incision approach and use of plates instead of lag
screws alone both help to reduce the risk of this deformity. Varus malunion affects the
biomechanics of the subtalar joint, which predisposes to the development of arthritis.[19]
Malunion should be evaluated with CT scan, and often requires corrective osteotomy.[54]
Nonunion is rare after talar neck fracture, typically occurring in the 3-5%
range.[10, 20, 28] If nonunion is associated with advanced arthritis, fusion may be
required.

7.4 Skin Complications and Infection

Soft tissue complications such as skin necrosis and deep infection are among the most
disastrous complications after talar fracture. There are a number of principles aimed at
minimizing the risk of these complications, including urgent reduction of dislocations,
administration of antibiotics and surgical debridement for open fractures, and meticulous
soft tissue handling during surgery. As stated previously, definitive surgical intervention
should be delayed until adequate resolution of swelling has occurred, which may take up
to 3 weeks after injury.[26]

8. SUMMARY
The role for non-operative treatment of talar neck or body fractures is limited to
nondisplaced or anatomically reduced fractures confirmed by CT scan. Any displacement
requires meticulous anatomic reduction and fixation. The use of dual anteromedial and
anterolateral approaches, plating, and bone grafting are paramount to a successful
reduction. As a result of these surgical tactics, the reported rate of osteonecrosis
following talar neck fracture has decreased over time, although it remains high. The
current gold standard treatment for end stage tibiotalar or subtalar arthritis following talus
fracture is arthrodesis of the involved joints. Lateral process fractures are easily missed,
but prompt diagnosis and appropriate treatment are important to ensure a good outcome.
Talar head fractures are rare, and depending on the percentage of talonavicular joint
involved, may be either excised or anatomically fixed.

Conflicts of Interest:
There are no conflicts of interest to report.

Acknowledgements:
None. This research did not receive any specific grant from funding agencies in the
public, commercial, or not-for-profit sectors.
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Figure Legend:

Figure 1. Superior and inferior views demonstrate the osseous anatomy of the talus. FHL
= Flexor Hallucis Longus.
Figure 2. Arterial supply to the talus from dorsal and plantar views. The major arterial
supplies are the 1) artery of the tarsal sinus (TS) from either the dorsalis pedis (DP) or
peroneal artery, 2) the artery of the tarsal canal (TC) from the posterior tibial artery , 3)
the deltoid artery from either the TC or the posterior tibial artery, 4) the posterior direct
branches (PT) from the peroneal artery, and 5) the superomedial direct branches of the
DP.
Figure 3A-E. Modified Hawkins classification system for talar neck fractures: (A) Type
I - Nondisplaced talar neck fracture, (B) Type IIA – Talar neck fracture with subtalar
subluxation (C) Type IIB – Talar neck fracture with subtalar dislocation , (D) Type III –
Talar neck fracture with subtalar and tibiotalar dislocation, and (D) Type IV – Talar neck
fracture with subtalar, tibiotalar, and talonavicular dislocations.
Figure 4. Clinical photograph of the incision used for the anterolateral approach to the
talus.
Figure 5A-E. Anteroposterior (A) and lateral (B) radiographs of a Hawkins type II
fracture with talar neck comminution and subtalar dislocation. Post-operative
anteroposterior (C), Canale (D) and (E) lateral radiographs demonstrate dual plate
fixation and reduction of the subtalar joint.
Table Legend
Table 1. Avascular Necrosis Rates by Hawkins’ Type

Table 1. Avascular Necrosis Rates by Hawkins’ Type

Hawkins’ Associated Hawkins, Dodd et al., 201512
Type Joint 19708 (Published after year
Subluxation or 2000, n=14)*
Dislocation
I None 0% 8.0%
II Subtalar 42% 20.7%
Subtalar
III 86% 44.8%
Tibiotalar
Subtalar
IV Tibiotalar __ 36.5%
Talonavicular
*Authors performed a meta-analysis of all studies reporting the rate of avascular necrosis
after talar neck fracture, and reported a separate rate for 14 studies published after 2000.
 Table 2. Case Reports of Talar Head Fracture

Author, Patie Fracture Mechanis Treatment Complications Follow

Year nt displaceme m -up
Age / nt (Mos.)
Sex
Ibrahim et 31/F Displaced Inversion Locking plate and NWB in Symptomatic 12
al., 201535 injury cast x 6 weeks hardware
while
walking
Long et al., 45/M Nondisplac NR Conservative (Delayed NR NR
201236 20/F ed NR Presentation) NR NR
16/M Nondisplac Football Conservative (Delayed NR NR
ed Presentation)
Nondisplac Conservative (Delayed
ed Presentation)
Matsumura 26/M Displaced Wakeboard Cast x 4 weeks Malunion 18
et al., ing (required
200837 medial talar
head osteotomy
and ICBG)
Mulligan et 27/M Nondisplac Gymnastics Walking cast x 4 weeks None 21
al., 198638 ed
Pehlivan et 22/M Displaced Inversion ORIF with K-wire fixation Persistent 26
al., 200239 injury and NWB in cast x 6 weeks lateral hindfoot
while pain
walking
Vlahovich 33/F Displaced Snowboard ORIF with 2.7mm Persistent pain 3
et al., ing compression screws and
200540 bone graft
NR= Not Reported, ORIF = Open reduction and internal fixation, NWB = Non-weight
bearing, ICBG = Iliac crest bone graft
 Table 3. Complications After Surgical Treatment for Talar Neck Fracture

Author, Year No. Talar Open AVN Malunion Nonunion PTA

Neck Fractures
Fractures
Chateau et al., 200226 23 NR 4 2 0 3
(17.3%) (8.7%) (0%) (13%)
Chen et al., 201434 48 NR 11/38 NR NR NR
(28.9%)
Elgafy et al., 20007 27 NR 7 NR NR 18
(25.9%) (66%)

Lindvall et al., 200414 16 NR 7/16 NR 2/16 16/16

(43.7%) (12.5%) 100%
Sanders et al., 200415 70 10/70 8/70 21/70 NR 54/70
(14.3%) (11.4%) (30%) (78%)

Tezval et al., 200749 41 11/41 5/31 NR NR NR

(26.8%) (16.1%)
Vallier et al., 200420 102 24/102 19/39 NR 3/60 21/39
(24%) (49%) (5%) (53.8%)
Vallier et al., 201410 81 24/81 16/65 NR 2/65 35/65
(30%) (25%) (3.1%) (54%)
Xue et al., 201428 28 0 6/28 NR 1/28 7/28
(0%) (21%) (3.6%) (25%)

NR= Not Reported, AVN = Avascular Necrosis, PTA = Post-traumatic arthritis, AOFAS
= American Orthopaedic Foot and Ankle Society ankle-hindfoot score, AOS = Ankle
Osteoarthritis Score, MFA = Musculoskeletal Function Assessment, SMFA = Short
Musculoskeletal Function Assessment, FFI = Foot Function Index