Talus body fracture management CLOSED REDUCTION/ OPEN REDUCTION

1. TALUS BODY FRACTURE
MANAGEMENT
DR ARJUN KOULOTH
ORTHO RESIDENT
LHMC
NEW DELHI

2. • 22 yr old male came with complaints of pain
in the right ankle x 10 days
• Apparently well 10 days prior to the
presentation when he sustained injury ( RTA-
bike)
• C/o pain + and swelling +
• Progressively increasing
• Aggrevated due to movements

3. On examination
• Swelling +
• Tenderness+
• Crepitus+
• Vascular status+
• No neurological deficits
• Deformity
• ROM

6. young, active, and mobile population
History of high velocity injury present
Clinically :-
• Intense pain , unable to move ankle, Gross
edema and echymosis usually present
• When there is subluxation or dislocation the
normal contours of ankle and hind foot are
distorted

8. PARTS OF TALUS
1. HEAD
2. NECK
3. BODY
4. LATERAL PROCESS
5. POSTERIOR PROCESS

13. • Roman Times- The heel bone of horse was
used as dice and was called Taxillus. This
Word evolved into Talus
• Year 1919-Anderson – reported the first series
of talar neck fractures in World War I pilots
and coined the term Aviators Astragalus

14. • 0.1 to 0.85% of all fractures
• 5 to 7 % of foot fractures
• 60 % is covered with articular cartilage

15. BODY OF TALUS
5 surfaces:
1. superior surface
2. Inferior surface
3.medial surface
4. lateral surface
5.posterior surface

16. NECK
• Constricted potion of bone between the body
and the oval head .
• Angle of medial deviation is 15 to 20 degree in
adults
• Plantar deviation is 24 degree approx
• Neck body angle is 150 degree in adults
• Relatively thin diameter makes it weaker area
and hence more vulnerable to fractures

17. TARSAL CANAL
Formed of sulcus of inferior surface of talus and superior sulcus of
calcaneum
Contents-
artery of tarsal canal and talocalcaneal interosseous ligament

18. • Posterior process has a medial and lateral tubercle
separated by a groove for the flexor hallucis longus
tendon

19. FRACTURE TALUS ANATOMICAL CLASSIFICATION OF
TALUS FRACTURE :-
1. Talar neck fracture
2. Talar body fracture
3. Talar head fracture
4. Lateral process fracture
5. Posterior process fracture

20. Talar body fractures
• intra-articular injuries (ankle and subtalar
joints)
• high-energy axial compression.
• The dorsally directed plantar force distal to
the talus may lead to a more posterior
fracture that involves the talar body rather
than the neck

23. AP and lateral
lateral process fractures
Canale View
optimal view of talar necK and body maximum equinus
15 degrees pronated
Xray 75 degrees cephalad from horizontal

26. Brodén view
Lat process # ,subtalar joint for any irregularity or
impaction fractures of the undersurface of the
talus.
• Beam aimed cephalad 10–40 degrees with respect
to the vertical with the foot in neutral position and
internally rotated at varying degrees from 20 to 60
degrees with respect to the vertical .

30. CT SCAN
• congruity of the subtalar joint
• significant fractures of the inferior aspect of
the talus, better on CT scan
• nondisplaced talus fractures as well as to
delineate the fracture pattern and degree of
displacement

32. EVEN 2 MM DISPLACEMENT ST JOINT ALTERED

34. PATHOLOGY
• Occur with axial load and a foot with muscles
in tension holding the foot in a rigid position.
• motor vehicle crashes cause the foot to be
axially loaded with the foot plate of the car
impacting a dorsiflexed foot on the brake
pedal.

44. • Deltoid branches are important to supply blood to
the medial talar neck and talar body.
• Branches from the dorsalis pedis supply the talar
head and most of the dorsal talar neck.
• The artery of the tarsal canal coming from
branches off of the posterior tibial artery supply
most of the talar body.
• The peroneal artery has the least contribution
laterally.

45. Müller/AO classification
• C1, C2 and C3 ascending order of severity.
• prognosis is progressively worse.
• A multifragmentary fracture with many
fragments bearing articular cartilage becomes
exceedingly difficult to reduce

46. • Ankle joint
involvement (C1)
osteochondral
injury to the
superior dome of
the body of the
talus.
AVN 0- 13%

47. Subtalar joint involvement (C2)
coronal split through
posteriorly displaced half blood
supply.
Avascular necrosis prognosis is
poor.
AVN 20-50 %

48. Ankle and subtalar joint involvement (C3)
•Comminution with the body
• congruency after reconstruction is often impossible,
AVN 83- 100 %

49. -

50. Sneppen classification

51. Boyd and Knight Classification
TYPE 1
• Shearing injury
CORONAL/ SAGITAL
TYPE 2
HORIZONTAL

52. Conservative management
• Undisplaced talar body fractures
• nonambulatory patients
• multiple comorbidities
short leg casting for 6 weeks until fracture
union.
Full weight bearing is allowed at the time of
complete radiographic union, usually after 8–
10 weeks.

53. • every unsuccessful attempt at closed
reduction increases the damage to the
already compromised ST
• Therefore, open reduction should be
considered even in high risk patients.

54. Techniques of reduction
1. First step to reconstruct the talar dome is to dis-engage all
the fracture fragments
2. Visualize the subtalar joint and clear the debris
3. Elevate and graft impacted fractures
4. Impaction on the subtalar side should be addressed first
5. Reduce the fracture fragments and pin them into place
6. Talar dome is reduced from posterior to anterior and from
lateral to medial .
Only after complete reduction of the body permanent fixation
should be done
7. Permanent fixations should lie in the medial or lateral gutter

55. Surgical Management
• Main goal in the treatment of talar body
fractures is to restore the joint congruity of
the tibiotalar and subtalar joints.
• Even in severely comminuted fractures
attempts should be made to restore at least
the tibiotalar joint

56. CLOSED REDUCTION
• Knee &foot flexed and varus
• Pin through calcaneum
• Direct pressure on body
• Per cut screw fixation and casting

59. COMMINUTED FRACTURES OF BODY
• Difficult to treat
• Accurate replacement of fragments is near
impossible
• Long term results- bad.
In such cases talectomy along with calcaneotibial
fusion is prefferred. gives patient painless and
stable walking foot

60. TIBIOTALAR ARTHRODESIS
PROCEDURE-
sliding graft from anterior surface of tibia is
inserted into the remnant of head and neck of
the talus in an attempt to obtain fusion
around the area

61. ADVANTAGES OF TIBIO TALAR ARTHRODESIS
OVER CALACANEOTIBIAL FUSION
• Position of foot is unchanged
• Weight bearing thrust is placed on more or
less normal undisturbed joint tissue.
• No shortening
• After surgery- still slight flexion and extention
of the foot on leg , in the two subtalar facets
and talonavicular joint is possible.

63. Surgical Approaches
based on the fracture location and pattern
• Posterior Approach
• Anteromedial Approach
• Anterolateral Approach
• Dual Anteromedial and Anterolateral
Approaches

64. Posterior Approach
• Incision is made between the posterior edge of
the medial malleolus and the medial border of
the Achilles tendon
• Deep interval can be made either anterior or
posterior to the flexor digitorum longus tendon,
depending on the fracture location

65. Anteromedial Approach
• interval between the tibialis anterior and tibialis
posterior tendons with the incision -anterior aspect
of the medial malleolus toward the navicular
• Anterior and medial articular surfaces of the talar
body, middle facet of the subtalar joint are readily
visualized
• oblique medial malleolar osteotomy is performed
after predrilling ( PRESERVING DELTOID BRANCHES)

68. A posteromedial approach to the body of the
talus would destroy its blood supply. Therefore,
if the body has to be exposed, one utilizes an
osteotomy of the medial malleolus
Most of the blood supply to the body is through
the deltoid branches of the posterior tibial
artery.

69. Anterolateral approach
• medial to the peroneus tertius tendon, and is
directed distally, parallel to the fourth metatarsal
• Superficial peroneal nerve
• extensor digitorum brevis is elevated
• osteotomy of the distal part of the fibula may be
indicated to gain access to the posterior portion
• Plantar flexing the foot to improve visualization

70. Dual Anteromedial and Anterolateral
Approaches
• Complicated talar body fractures with coronal
displacement, comminution, or associated talar
neck fractures
• Plantar dissection along the talar
neck is avoided - to protect the tarsal canal
• fibers of the deltoid ligament should also be
preserved
• Dorsal neck vessels are protected

72. Fixation options
• Screws(2-4 mm)( headless preferred()
• AP/PA
• PA : Theoretically better/perpendicular
• Titanium (thordarson et al) for future MRI to
assess AVN
• LAG SCEW in noncommunated #
• Compression scew antero lateral to postero
medial( bone is denser and no varus
malalignment)

73. • Postoperatively,
Nonweight bearing cast x 6 weeks
Ideally ankle in a dorsiflexed position to ensure bony
reduction and minimize anterior scar tissue
formation.
• After 6 weeks, gentle, nonweight bearing ROM
(subtalar and ankle joints)
• Nonweight bearing continued for a full 12 weeks

75. Complications
• skin infection and subsequent necrosis
• AVN
• Malunion
• nonunion
• late osteoarthritis
• ankylosis of subtalar joint.
• Most common reason for secondary surgery=
subtalar arthritis

76. • nonunion after talar neck or body fractures is
rare, occurring in <5%
• malunion in previous reports varies between
0% and 37%
• 65% incidence of posttraumatic tibiotalar
arthritis
• 34% incidence of posttraumatic subtalar
arthritis.

79. talar body involve both the tibiotalar and subtalar
joints, and have the highest incidence of arthritis
among all talus fractures.

83. • nonunion after talar neck or body fractures is
rare, occurring in <5%
• malunion in previous reports varies between
0% and 37%

84. Heather A. Vallier, MDJ Orthop Trauma Volume 29, Number 9,
September 2015

85. Heather A. Vallier, MDJ Orthop Trauma Volume 29,
Number 9, September 2015