Talar Fracture

Dr Ramin Maharjan
First year resident, Dept of Orthopaedics, PAHS
Moderator: Dr Amrit Shrestha

Date: 26th October, 2021

Contents
• EPIDEMIOLOGY
• MECHANISHM OF INJURY
• CLINICAL FEATURES
• CLASSIFICATION
• RADIOLOGICAL DIAGNOSIS
• MANAGEMENT
• COMPLICAITON
History
• Roman times – heel bone of horse was used as dice and was called
TAXILLUS. The word evolved into Talus
• 1919 – Anderson – reported first series of talar neck # in world war I
pilots and coined term Aviator Astragalus
• 1970 – Hawkins – presented classification of neck of talus # based on
the pattern of injury and disruption of blood supply
• He determined the risk of osteonecrosis to talar dome

• 1978 – Canale and Kelly – expanded Hawkins classification system and

introduced type 4
Incidence of talus fracture
• 0.1 to 0.85% of all fractures

• 5-7% of foot fractures

• 50% talar neck fracture

• Talar body fracture contributes 13% to 20% of all injuries to the talus
Relevant Anatomy
• Second largest tarsal bone

• Ossification – from one center which appear in 6th month of

intrauterine life

• 60% is covered with articular cartilage

It acts as a connecting link between the Foot
and the Leg

Unique tarsal bone

Talus articulated with 4 bones

Tibia
Fibula
Calcaneus
Navicular
Morphology of Talus
• Parts of talus
• Head
• Neck
• Body
• Lateral process
• Posterior process
Neck of talus
• Constricted portion of bone between body and oval head
• Directed forward, medial, downward
• Angle of medial deviation is 15-20 degree in adults
• Plantar deviation is ~24 degree
• Neck body angle is 150 degree in adults
• Relatively thin diameter makes it weaker area and hence more
vulnerable to fractures
• Tarsal canal
• Formed of sulcus of inferior
surface of talus and superior
sulcus of calcaneum

• Contents:
• Artery of tarsal canal
• Talocalcaneal interosseous
ligament
POSTERIOR PROCESS :
• It has Medial and Lateral tubercle
• Lateral : Anterior, Lateral, and
Posterior Talofibular Ligament
• Medial : Deltoid ligament
• OS TRIGONUM - seen in 50% people,
develops from separate ossification
centre posterior to Lateral tubercle
• Multiple Ligamentous Attachments
• Anterior talofibular ligament
• Posterior talofibular ligament
• Talocalcaneal ligaments
• Tarsal Sinus ligaments
• cervical ligament
• talocalcaneal interosseous ligament
• Deltoid ligament
• Anterior tibiotalar ligament
• Superficial posterior tibiotalar ligament
• Deep posterior tibiotalar ligament
• Dorsal talonavicular ligament

Figure 64-4 and 64-5: Tornetta P, Ricci WM, eds. Rockwood and Green's Fractures in Adults, 9e.
Philadelphia, PA. Wolters Kluwer Health, Inc; 2019..
 Complex Vascular
Supply
• It receives blood supply through Capsular and Ligamentous
attachments, and Nutrient foramen in the Neck

• Posterior Tibial Artery (47%)

• Artery of Tarsal Canal
• Main Contributor Talar Body
• Deltoid Branch
• Anterior Tibial Artery
• Artery Tarsal Sinus
• Perforating Peroneal Arteries
Complex Vascular
Supply
Anatomical classification of Talus fracture
• Talar neck #
• Talar body #
• Talar head #
• Lateral process #
• Posterior process #
AO/OTA classification of talus fracture
Hawkin classification of talar neck #
• Based on displacement of body of talus
• 1970 – talar neck # into 3 types
• Canale and Kelly added type 4
• Vallier et al. modified Hawkins classification into type IIA (subluxated
subtalar joint) and type IIB (dislocated subtalar joint) subcategories

• Useful to predict long term outcome and development of AVN of talar

body.
HAWKIN’S CLASSIFICATION
• Type I : Nondisplaced
• Type II : Displaced with Subtalar Subluxation
• Type III : Displaced with Subtalar and Ankle subluxation
• Type IV : Displaced with Subtalar, Ankle and Talo-Navicular
subluxation
 I II III
IV
Classification AVN risk %
I 0-13
II 20-50
III 20-100
IV 70-100
Mechanism of injury for talus #
• Low to high energy trauma
• Different areas of talus may be injured depending upon direction of
force and position of foot
Mechanism of injury
• Talar neck fracture
• Fall from a height
• Motor vehicle accident

• Hyperdorsiflexion with axial plantar force

• If force continues, posteromedial dislocation of talar body , often around
deltoid ligament

• This mechanism is consistent with historical aviation crashes as well as

injuries seen in motor vehicle collisions with the midfoot on the brake pedal.
Mechanism of injury
• Talar body fracture
• Mode of injury is similar to talar neck fracture

• Axial compression when talus is anteriorly subluxated and anterior plafond

impacts on the talar dome

• overall combined injury (talar body and neck) incidence of 40%.

Mechanism of injury
• Talar head fracture
• Compressive and shearing forces across the talonavicular joint

• shear fractures result from subluxation or dislocation of the talonavicular

joint, either with inversion and plantarflexion, or eversion and dorsiflexion

• Fractures can occur along the axial or coronal planes

• an extension of the forces seen with talar neck fractures

Mechanism of injury
• Talar process fracture
• Lower energy pattern
• Rotational forces associated with inversion and eversion of foot

• Lateral process fractures or “the snow-border's fracture” is caused by an axial

force with the hindfoot in eversion and the ankle in dorsiflexion
Mechanism of injury
• Posterior process fractures involve the posterior aspect of the lateral tubercle.
• This injury usually is a result of axial compression with the ankle in extreme
plantarflexion

• Chronic repetitive stress with the foot in plantarflexion as seen in kicking

sports or dance can create a stress fracture of the posterior process.

• can also be confused with a symptomatic os trigonum, which occurs due to

failure of ossification between the posterior process and talar body during
development
Mechanism of injury
• Fractures of the medial tubercle are more uncommon than lateral
process fractures.
• avulsion of the bone fragment by the posterior talotibial ligament
when the ankle was dorsiflexed and pronated
• Other - impingement of the sustentaculum tali in supination and
direct trauma to the posteromedial talar facet

• difficult to diagnose, and are commonly found using advanced

imaging techniques
Injuries associated with talus fracture
• high-energy mechanisms
• 59% had associated ipsilateral injuries
• fractures of the medial and lateral malleolus with incidence of 19%
and 28%
• Associated fractures of the calcaneus and tibial plafond, as well as
syndesmotic injuries
Clinical presentation
• Talus # frequently occur in a young, active and mobile population
• History of high velocity injury

• Clinically
• Intense pain, unable to move ankle,
• Gross edema and ecchymosis
• Subluxation or dislocation – normal contour of ankle and hind foot are
distorted
• Open injury
careful neurovascular examination
• Pulse
• Ankle brachial index
• Neurological examination – posterior tibial nerve compression
• Assess ROM of ankle and hind foot
• Palpable pain posteriorly or pain with ankle plantarflexion may be due
to a posterior talar process fracture
• Abnormal motion at the hindfoot or talonavicular joint may be an
indication of a talar head fracture
• lateral ankle ligament stability
Diagnosis
• Radiographic evaluation

Xrays
• Antero posterior view
• Ankle mortise view
• Lateral view
• Canale view
CANALE VIEW
• view of the talar neck achieved by
internal rotation of the foot by placing
the foot plantigrade on an x-ray film and
angling the beam at 75 degrees to the
horizontal

• Gives best view of talus neck

• True AP view of talus neck

• Useful intraoperatively to check

alignment of neck
Hawkin’s sign
CT scan
• Give excellent visualization of the
congruity of the subtalar joint and
provide superior details of fracture

• Small but significant fractures of the

inferior aspect of the talus, are better
appreciated on CT scans compared to
plain x ray films
MRI scan
• Demonstrated osteonecrosis most
effectively
Treatment
Goals:
• Immediate Reduction of dislocated joint
• Early anatomic reduction of fracture
• Stable fixation
• Facilitate union
• Avoidance of complications
Treatment
• Nonoperative
• Operative
Nonoperative Treatment of Fractures of the
Talus
Indications Relative Contraindications
• Nondisplaced talar neck fracture • Fracture
• Nondisplaced talar body fracture displacement/instability
• Nondisplaced talar head fracture • Ankle or subtalar incongruity
• Nondisplaced talar lateral or posterior
process fracture • Nonunion or incomplete healing
• Incomplete or stress fracture of the with persistent pain
neck, body, or head
• Poor surgical candidate—critical medical
comorbidities, nonambulator with spinal
cord injury/neuropathy
Nonoperative treatment
• Talar avulsion # - immobilization, early weight bearing and gradual
functional rehabilitation

• Smaller fragments of lateral process # and small fractures of posterior

tuberosity -
• Non weight bearing for atleast 6 weeks followed by protected weight
bearing and range of motion exercises
• Close radiographic follow up to monitor displacement and joint
instability
• Talar head fracture –
• nonweight-bearing cast
• followed with progressive protected weight-bearing at 10 to 12
weeks
• fractures of the talar neck in patients who have poor soft
tissue envelopes, or are not surgical candidates,
• cast immobilization for 4 to 6 weeks
• followed by continued immobilization in a fracture boot with
range of motion exercises.
Operative treatment
• all displaced fractures (Hawkins II-IV)
• Talus extrusion
Treatment of Talar Neck Fracture
• Emergent reduction of dislocated joint
• Stable internal fixation
• Debridement of subtalar joint
• Maintain as much soft tissue
• Choice of fixation and approach depends upon fracture personality
Closed Reduction Technique
• Adequate sedation
• Flex knee to relax gastrocnemius
• Traction on planter flexed forefoot to realign head with body
• Varus/valgus correction as necessary
• Direct pressure on talar body
• Adjunct: traction pin, general anesthetic
• Avoid repetitive reduction attempts in order to avoid skin compromise
or tearing
Dislocated talar body in Hawkins III
• talar body is often extruded posteriorly or posteromedially. In the
latter case, the fragment can often become buttonholed, making
closed reduction impossible. After induction and sedation in the
operating room, the leg should be flexed at the knee to relax the
gastro-soleus complex. Longitudinal traction should be applied with
the foot in a plantarflexed position. This opens the posterior ankle
space and the fragment can then be manipulated back underneath
the plafond using manual pressure. Subtle additional varus or valgus
forces may aid in the reduction. Once the body is reduced, the foot is
held in plantarflexion and a well-padded, molded splint is applied
External Fixation
• Limited roles
• Multiple injured patient with talar neck
fracture in whom definitive surgery will
be delayed
• Temporizing measure to stabilize
reduced joints
• Construct bridges tibia- calcaneus -
midfoot
Hawkins I
Fracture
• Non Operative & Non-Weight-Bearing
Cast
OR:
• Percutaneous screw fixation and early
motion
• AP screws acceptable treatment/union
• Limited risk to surrounding structures
• PA screws
• Biomechanically superior
• Perpendicular to fracture line
• Increased risk to surrounding structures
FHL/sural nerve
Hawkins II, III, and IV
Fractures:
• Results dependent upon development of complications
• Osteonecrosis
• Malunion
• Arthritis
Surgical Approaches
• Single Incision technique:
• Anteromedial or
• Anterolateral

• Difficult to visualize the entire talar neck and subtalar joint without
significant soft tissue stripping and devascularization
• 2 incision technique preferred
• Anteromedial and lateral/anterolateral approach
Principle of Surgical Treatment
• Achieve anatomic reduction
• Utilize dual incisions
• Maintain capsular soft-tissue insertions to protect blood flow
• Allows for visualization and correction of medial talar neck comminution
• Utilize osteotomies as necessary
• Take x-ray of uninjured side for morphology comparison
 1st Approach: anteromedial
• Medial to Tib Ant
• Make incision more posterior for
talar body fractures to facilitate
medial malleolar osteotomy (if
osteotomy planned)
 1st Approach:
• Provides view of neck alignment and medial comminution
• Extend incision distally to talonavicular joint – hardware is placed distal to
proximal and needs to be well countersunk to avoid impingement
2nd Approach: Lateral
• Tip of Fibula Base of the 4th metatarsal
• Mobilize EDB as sleeve
2nd Approach:
• Visualizes Anterolateral alignment and subtalar
joint
• Allows for debridement of debris in subtalar
joint
• Facilitates Placement of “Shoulder Screw” or
lateral plate
2 incisions: Skin
bridge
• Narrow skin bridge but generally
well tolerated
• Be sure to not dissect the dorsal
capsular structures to the distal
neck /head
Fixation
Options
• Stable Fixation to allow early motion is the goal
• Often a combination of mini-fragment plate fixation and screw
fixation
• Depends on fracture comminution and medial neck shortening
• Consider fully-threaded screws medially to prevent medial neck shortening
and varus
• Lateral plating for buttress
Surgical tactics: Fixation
• Implant selection depends upon comminution and bone quality
• Anterior
• Partially threaded screw
• Fully threaded screw
• Minifragment plates (2.0, 2.4 mm)
• Posterior
• Lag screws
Anterior Screw
Fixation:
Screw fixation alone is acceptable for non-
comminuted fractures, but consider adding
a lateral plate if there is comminution.
• Easy to insert under direct
visualization
• Countersink screw heads if encroaching on
articular surfaces
• No difference in strength of countersinking
vs headless screws
Plate
Fixation:
• Very useful in comminuted
fractures:
• 2.0 or 2.4 mm plates
• Easiest to apply to lateral cortex –
impinge on medial side
• Provides a length stable construct
• Careful contouring of the lateral plate to
prevent subfibular/lateral gutter
impingement
Talar Body Fracture
Management
• Shear • Compression
• Nondisplaced • Highly comminuted
• Non-op treatment with • Acute fusion
• Blair fusion
immobilization/nonwe
i ghtbearing • Strut from
anterior tibia
• Displaced • Tibiocalcaneal
• ORIF fusion
• Countersink screws
• Headless
compression screws
Talar Body
Fractures
• Be aware of threatened
skin from fracture
fragments
• Use both lateral and medial
malleolar osteotomies/fractures
for visualization

Lateral Skin tenting

from lateral body
fragment
 Talar Body
Fracture
• Similar fracture fixation principles as the
talar neck fracture
• Plate fixation in highly comminuted fractures
with impaction and bone loss
• AVN rates and posttraumatic OA rates increase
with fracture severity
• No significant difference in posttraumatic OA
and rates of AVN when compared to talar
neck fractures
 Treatment of Talar Head
Fracture
• Requires 2 incisions to debride
subtalar joint from lateral
approach, and reduce / stabilize
fracture from medial side
• Consider bridge plating across
the fracture to maintain length
and prevent collapse

Figure 60-30: Tornetta P, Ricci WM, eds. Rockwood and Green's Fractures in
Adults, 9e. Philadelphia, PA. Wolters Kluwer Health, Inc; 2019.
Lateral Process
Fractures
• Can lead to subtalar OA and deformity through the subtalar joint
• Can also see cartilage damage of the posterior facet subtalar joint
Treatment Options
• Non-operatively for minimally displaced fractures

• Excision of fragment

• Isolated mini fragment screws

• Mini plate fixation

Posterior Talar Process
Fractures
• Medial tubercle fracture: “Cedell’s fracture”
• Lateral tubercle: “Shepherd’s fracture”

• Treatment: immobilize or excise or ORIF

• Use low profile fixation to prevent posterior impingement or FHL
tendon irritation
Open Talar Body
Extrusion
• Catastrophic Injury
• 60% Open injuries
• Infection Rates 25-50%
• Reinsert extruded bone after thorough
washing
• Maintain bone stock
• Maintain height
Postoperative Care
• similar for all fractures of the talus.
• The patient is initially splinted in a neutral position.
• transitioned into a removable fracture boot at 2 weeks
• if the soft tissues are stable, and ankle and subtalar range of motion
exercises are initiated.
• Nonweight-bearing precautions are continued for 10 to 12 weeks.
• then transitioned into an ankle brace and physiotherapy is started.
Complications
• Delayed wound healing/superficial infection Osteomyelitis
• AVN - 31% overall
• Without collapse
• With collapse
• Nonunion and delayed union
• Malunion
• Varus – 25-30%
• Posttraumatic arthritis
• Tibiotalar – 33%
• Subtalar – 50%
• Combined
References:
• Rockwood and Green’s Fractures in Adults 8th Edition
• AO principle of fracture management 3rd Edition
• Apley & Solomon's System of Orthopaedics and Trauma 10th edition
• Campbell’s Operative orthopaedics 13th Edition
• THANK YOU