Brief overview of Talar Fractures

1. Fractures of the Talus
Prepared by Dr Madan Mohan
Consultant, KIMS Hospital , Trivandrum
Based on Orthop Clin N Am - (2016)

2. •The talus consists of 3 main sections (body,
head, and neck) and 2 processes (lateral and
posterior processes).
•The posterior process is composed of 2 tubercles
(posteromedial and posterolateral tubercles).
•Articular cartilage covers more than 65% of the
talar surface, and no tendon or muscle
attachments originate from the talus

3. • The extraosseous blood supply includes branches from the posterior
tibial artery (artery of the tarsal canal, deltoid branches), branches
from anterior tibial artery (dorsalis pedis branches), and branches
from the peroneal artery (posterior tubercle branches, artery of tarsal
sinus).
• The artery of the tarsal canal (branch of the posterior tibial artery)
gives off the deltoid branches supplying the medial talar body.
• The artery of the tarsal canal continues distally to join the artery of
the tarsal sinus (branch of the peroneal artery) forming an important
anastomosis inferior to the talus

6. Clinicians must maintain a
high index of suspicion for
any patient presenting with
hindfoot pain after an acute
injury

7. FRACTURE CLASSIFICATION
The Orthopedic Trauma Association (OTA) has
extensively classified talus fractures, in which the
fractures are divided into head fractures (81-A),
neck fractures (81-B), and body fractures (81-C).

8. TALAR HEAD FRACTURES
• very uncommon, accounting for less than 10% of all talus fractures
• compression and shear forces have been described as mechanisms
for injury.
• unlike neck and body fractures, osteonecrosis is uncommon in talar
head fractures, but posttraumatic arthritis is a likely complication
following intra-articular fractures.

9. • The principles of treatment include maintenance of the
medial column length and height, and restoring
talonavicular joint congruity, stability, and motion
• Small comminuted fractures may be excised to restore
talonavicular motion, but larger fragments are stabilized
with headless screws, mini-fragment screws, or
bioabsorbable implants
• Minimizing dorsal dissection, dorsal, or medial approaches
are used depending on the fracture location

10. A) Displaced talar head fracture, (B) subsequent
ORIF with mini-fragment lag screws.

11. TALAR NECK FRACTURES
• accounts for nearly half of all significant injuries to the talus.
• the neck is void of articular cartilage, providing a site for soft tissue
attachments and vascular foramen
• Adjacent to the inferior talar neck, the artery of the tarsal canal
joins the artery of the tarsal sinus forming an important
anastomosis

12. • Hawkins classified talar neck fractures in 1970.
• A Hawkins type I refers to a nondisplaced fracture of the talar neck.
• In a Hawkins type II, the neck fracture is accompanied by subtalar joint
subluxation or dislocation. Type II fractures are the most common.
Recently, Vallier suggested a modification of the Hawkins type II
fracture, adding types IIA and IIB. In type IIA, the subtalar joint is mildly
subluxated, and in type IIB, the subtalar joint is dislocated
• Talar neck fractures with tibiotalar and subtalar incongruity represent
Hawkins type III fractures.
• Last, Canale and Kelly added the type IV modification, in which neck
fractures are accompanied with complete talar dislocations (ie,
tibiotalar, talonavicular, and subtalarjoint incongruity

13. Hawkins
Classification of
Talar Neck
Fractures

14. • For completely nondisplaced fractures (Hawkins type I), treatment
consists of immobilization and non-weight-bearing for 6 weeks or
until radiographic union.
• If the fracture line is easily visible on radiographs, then the fracture
should be appropriately classified as a Hawkins type II, and
conservative treatment is not recommended.
• For any displaced neck fractures, anatomic reduction and rigid
fixation are recommended.

15. (A–C) Hawkins
type II fracture, (D,
E) imaging after
ORIF, (F) arrow
highlighting the
subchondral bone
absorption
(Hawkins sign).

16. Use of a medial
malleolus
osteotomy to
visualize a talar
dome fracture.
The arrows
indicate predrilled
tunnels for later
osteotomy fixation

17. TALAR BODY FRACTURES
• The mechanism of injury typically involves high-energy compression
between the tibial plafond and the calcaneus, but low-energy
shearing forces can also generate body fractures
• Talar body fractures include lateral and posterior process fractures,

18. TALAR BODY FRACTURE
VARIANTS
(PROCESS AND
OSTEOCHONDRAL
FRACTURES)

19. Lateral Process Fractures
• The lateral process involves both the tibiotalar joint at the fibular
articulation and the subtalar joint at the posterior facet.
• The talocalcaneal, anterior talofibular, and posterior talofibular
ligaments originate from the tip of the lateral process, providing
stability to the ankle joint.
• Occurring more frequently in snowboarders
• Frequently overlooked as simple ankle sprains, but these fractures
can cause debilitating pain

20. • These fractures are best visualized with an ankle mortise view
• Small, nondisplaced fractures can be treated with partial
weightbearing and immobilization for 6 weeks.
• For large, displaced fractures, ORIF is recommended, but for small,
displaced, or highly comminuted fractures, simple excision is
recommended

22. Posterior Process Fractures
• Fractures of the posterior process involve posterior lateral and
posterior medial tubercle fractures.
• The posterolateral tubercle is the larger of the 2 tubercles. The
proximal surface of posterolateral tubercle is nonarticular and
provides insertion for the posterior talofibular ligament and
fibulotalocalcaneal ligament.
• The medial tubercle is of variable size and provides attachment for
components of the deltoid ligament, medial talocalcaneal ligament,
and the flexor hallicus longus tunnel.
• The inferior surface of the posterior process articulates with the
posterior facet of the calcaneus.

23. • Posterolateral tubercle fractures occur with forced plantar flexion,
causing direct tibial impaction, or with excessive dorsiflexion,
resulting in the posterior talofibular ligament avulsing the lateral
tubercle
• Large, displaced fractures that involve a significant portion of the
subtalar joint should undergo ORIF through a posterolateral
approach.
• These fractures more truly involve the talar body proper. Otherwise,
most posterolateral process fractures are typically treated
conservatively with non-weight-bearing and immobilization

24. • Posteromedial tubercle fractures are more difficult to visualize with
radiographs, making a meticulous history and physical examination
vital for accurate diagnosis
• Tenderness to palpation over the posteromedial ankle behind the
medial malleolus
• With its proximity to the tibial nerve, displaced fractures have been
reported to cause tarsal tunnel symptoms
• Displacement can block the movement of the subtalar joint, resulting
in posttraumatic arthritis and subsequent arthrodesis.

25. Radiographic and CT imaging of
posteromedial process fracture.

26. LATERAL INVERTED OSTEOCHONDRAL
FRACTURE OF THE TALUS LESIONS
• These lesions are often inverted, in which they are appropriately
termed LIFT lesions (lateral inverted osteochondral fracture of the
talus
• These are seen in gymnasts
• These fractures represent an intra-articular loose body that should be
treated surgically through an arthroscopic or open approach

27. Radiographic and CT imaging of LIFT lesion.

28. TALAR EXTRUSION
• Complete dislocations through an open skin wound are termed talar
extrusions
• Essentially, surgeons have the choice of reimplantation or talectomy
with arthrodesis
• If the gross contamination can be removed, then it is generally
recommended to attempt reimplantation.
• Before reimplantation, the talus should be treated with a 5-minute
chemical soak (ie, 10% povidone-iodine or 4% Chlorhexidine)
followed by a saline wash

29. TIMING OF TREATMENT: ORTHOPEDIC
EMERGENCY?
• The amount of initial displacement rather than timing of definitive
fixation affected osteonecrosis rates.
• Osteonecrosis never occurred in Hawkins type I or Hawkins type IIA
fractures, but occurred in 25% of Hawkins type IIB, 41% in Hawkins
type III, and 33% in Hawkins type IV.
• The overall rate of osteonecrosis was 25%
• The time of injury to emergent reduction within 6 hours, 8 hours, 12
hours, or 18 hours did not correlate with osteonecrosis, and the time
to definitive fixation did not correlate with higher AVN rates.

30. Surgical
Approaches to
the Talus