2. TALUS
IInd most common tarsal fracture
60% coverage by articular cartilage
no tendon / muscle attachments
Tenuous blood supply
90% of motion of foot / ankle
Body, neck, head, lat. and post.
processes
3. Blood supply
Branches from post. and
ant. tibial arteries,
Perforating peroneal
arteries
Anastomoses in sinus tarsi
and tarsal canal
inferior sling
Capsular and ligamentous
supply
7. Talar neck fracture
Mechanism – hyperdorsiflexion or direct axial
load e.g MVA, fall from height, “aviators
astragalus”
Posterior capsule ruptures , talar neck impacts
on distal tibia , vertical fracture.
Foot subluxes forwards > talar body in equinus.
Or
Pushed postero-medially out of mortice sits
between medial malleolus and tendo Achilles.
8. Talar neck fracture
Osteonecrosis depends on degree of
displacement.
Undisplaced disrupt intra-osseous
branches of sinus tarsi / tarsal canal
arteries
but major sling remains intact.
If Displaced above -- disrupt dorsalis
pedis branches to neck.
10. Talar neck fracture
Treatment
Best results with prompt,
accurate anatomical
reduction & maintenance
Type I – absolutely no
displacement / ST
incongruency
BK cast 6 -12 weeks
(NWB 6 weeks)
11. Talar neck fracture
Treatment
Type II – prompt closed
reduction, traction,
plantarflexion,
correct varus /valgus
Xray – in equinus
BK cast in equinus
(6weeks), cast for up to
3 months & 2 weekly
Internal fixation
(antegrade fixation)
12. Type II Talar neck Fracture
Treatment
Avoid multiple attempts at
closed reduction.
Open reduction -
Antero-medial or antero-lateral
approach
Cannulated screws (4.5/ 6.5
mm) (titanium)retrograde or
antegrade– beware penetration
talo-navicular joint NWB cast 6-
12 weeks
13. Talar neck fracture
Treatment
Type III – 25% open
Closed – prompt reduction, closed
reduction often impossible
?Arthroscopic assisted reduction
Open reduction – postero-medial or anteromedial
approach
Leave deltoid ligament fibres intact
Osteotomise / fractured medial malleolus
14. Internal fixation –
cannulated compression
screws (avoid
comminuted medial neck)
Delayed primary closure
at 5-7 days
BK cast NWB 3 months
Treatment
15. Treatment
Type IV –
manage as for
III, and reduce
talo-navicular
joint(usually
heals in cast)
Prognosis related
to displacement of body
Talar Neck Fracture
16.
17. Fractures neck
with subtalar
dislocation and
post dislocation
of Talus
Emergency
Immediate
Reduction
1942 – Boyd &
Knight – Red and ST
Arthrodesis
1957 - Bohler –
Open reduction If
close Red fails-
1959 - Allgower –
open red and lag
screw
1962 - Watson
Jones –open
reduction If close
Red fails
1963 - Mc Keever
Red and Triple
Arthrodesis
20. Points to remember
ORIF may not be
easy. Be prepared
to do medial
Malleolus
Osteotomy – use
of Calcaneal pin
Save Talus – Be
prepared to face
AVN
21. Talar neck fracture – Complications
Skin Necrosis and Infection
Prompt reduction, debride the open wounds
and leave open.
Persisting infection > radical debridement of
body.
Best results from excision of sequestered talus
and tibio-calcaneal fusion.
22. Talar neck fracture
Malunion
Varus – lateral weight bearing Subtalar joint stress
secondary arthritis (osteotomy and bone graft)
– Dorsal displacement of head -- reduced dorsiflexion,
pain (excise dorsal talar beak)
Delayed Union / Non-union
Delayed union common, but Non-union rare (0-4%)
Poor blood supply, limited periosteum on neck
No healing at 12 months > Cortico-cancellous bone
graft
23. Blair Fusion-- Advantages
Position of foot unchanged
Backward displacement not
required
Foot & Ankle relationship not
disturbed
Limb not shortened
Preserves some Sub- Talar Motion
24.
25. Talar neck fracture
Complications- Osteonecrosis
Degree varies with
injury, but still need
early, accurate
reduction to reduce its
secondary effects.
Type I : 0-13%
Type II : 20-50 %
Type III : 83-100%
26. X-ray – increased radio-
density talar body
Later – collapse of
subchondral bone,
reduced joint space,
fragmentation of body
MRI clearly defines
presence and extent of
involvement.
Talar neck fracture -
Osteonecrosis
27. Talar neck fracture -
Osteonecrosis
“Hawkins’ sign” – high
sensivity, moderate
specificity.
At 6-8 weeks, disuse
atrophy because NWB.
AP X-ray- subchondral
atrophy in dome, implying
vascularity
28. Talar neck fracture - Osteonecrosis
Primary goal is union, which still occurs,
therefore continue NWB, even if no Hawkins
sign.
Once united, still need up to 3 years before
revascularisation /PTB brace/NWB
If dome collapse and pain, identify joint/s
involved and arthrodese.
Usually tibiotalocalcaneal fusion.
29. Talar body fracture
20% talar fractures
Classification - Sneppen (1977)
I - Osteochondral dome fracture
II – Coronal, sagittal, horizontal Shear
fractures
III – Posterior process fractures
IV – Lateral process fractures
V – Crush fractures
30.
31. 1% talar fractures
Mechanism:
– dorsiflexion / inversion anterolateral lesion
– plantarflexion / inversion posteromedial
lesion
Often not visible on Xray > persistent pain
weeks after “sprain” +/- locking
Bone Scan - sensitive, but not specific
MRI – identification and classification
Osteochondral Dome
Fracture
32. - Classification
Anderson (1989)
I – subchondral trabecular compression
II – incomplete separation of fragment
IIa – subchondral cyst
III – fragment not attached, but remains in
normal position
IV – displaced fragment loose within joint
Pritsch arthroscopic grading of cartilage
condition (firm, soft, frayed)
Osteochondral Dome
Fracture
33. Osteochondral Dome
Fracture
Treatment
Incidental finding at ORIF > remove or fix
Incidental finding on Xray > observe
Symptomatic
– Stage I / II - BK cast 6 - 12 weeks NWB
– If still symptomatic > soft > leave NWB or drill
cartilage
frayed > debride & curette
– If >1 cm and subchondral bone fix with absorbable
pin
34. Osteochondral Dome
Fracture
-Treatment
Stage III – prolonged NWB versus early surgery
- Arthroscopy > debride fragment & curette
underlying bed
Stage IV – remove loose body, if bed covered by
fibrocartilage > leave, if frayed debride to
bleeding subchondral bone / mosaicplasty
Results - 50% have pain on activity
(Pettine & Morrey, Angermann & Jensen)
35. Shear Fractures of Body
Fracture line extends into dome, or
into subtalar joint.
MVA, fall from height. Generally
poor long-term results. Higher risk
of osteonecrosis.
AP / lateral / mortice / CT
Undisplaced -- BK cast until radiol
signs of healing
Thordarson (2001) > 1mm+
displacement -- ORIF via medial
malleolar osteotomy
Complications > osteonecrosis –
NWB up to 2 years, arthritis 75%
36. Lateral Process Fracture
Snowboarder’s Fracture
25% talar fractures
May extend into subtalar joint (bigger fragments)
Mechanism – dorsiflexion and inversion.
AP / mortice / CT
Undisplaced – BK cast NWB 6 weeks
Displaced >2mm / 1cm fragment > ORIF
Prognosis – often present with nonunion or arthritis
months after injury. Best results with undisplaced
fracture or accurat reduction. May need late excision
of non-united fragments
or subtalar fusion
37. Posterior Process Fracture.
Lateral tubercle fracture
– Mechanism : inversion or
compression
(extreme equinus)
– DDx: os trigonum
– Xray : lateral, Bone Scan
– Treatment : undisplaced –
BK cast 4-6 weeks
– Persistent pain and
stiffness – excise non-united
fragment
38. Posterior Process Fracture
Medial tubercle fracture
– Rare, pronation in dorsiflexion (athletes)
– Present late with medial pain and swelling
– Xray : lateral, avulsed medial fragment on
AP
– Undisplaced : BK cast 6 weeks
– Displaced : ORIF especially if ST joint
involved.
– Non-union : persistent pain > excise
fragments
39. Crush fracture
Uncommon, high complication rate.
Usually significant displacement, and subluxed
subtalar /
ankle joints
C. T
Treatment : anatomical reduction via anteromedial
arthrotomy +/- osteotomy medial malleolus, pins /
screws
for large articular fragments. Bone graft / substitute.
If stable fixation, early ROM post-op
Complications : osteonecrosis, arthritis, malunion
40. Fractured Head of Talus
Uncommon.
Usually involves talo-
navicular joint.
Mechanism :
compression of
head, plantarflexed foot.
Xray : AP / lateral /
oblique –
check navicular and
calcaneo-cuboid joint.
41. Fractured Head of Talus -
Treatment
Undisplaced : BK cast NWB 6 - 12 weeks, then
medial arch support 3-6 months
Displaced : anatomical reduction via anteromedial
approach. Excise comminuted fragments.
Complications : persisting subluxation and
arthritis.
Talo-navicular pain may improve with
firm longitudinal arch support.
If fails, then arthrodesis talonavicular joint or
entire midfoot (test with local anaes. injections)
42. Association with
Fracture calcanceum
Talus may be
subluxated or
fractured along
with fracture
calcanceum - a very
rare injury.
Total Talectomy
Tibio Calcaneal
Fusion
43. Points to Remember
Earlier the reduction the better are the
chances of success
Subtalar subluxation and dislocation should
not be missed
Deforming force is the key to reduction
Do not hesitate to put calcaneal pin
Immobilisation for longer period
Appreciate the jeopardised blood supply the
foot
Treat As Emergency
44. Recognise the Collapse of talus
BLAIR fusion is the Best.
Tibio calcaneal fusion to be
undertaken as a last resort
Rare fractures to be kept in mind