Talus fracture treatment

1. Kumar Shantanu Anand MS (Orth.), Dip.SICOT
Consultant, ANAND HOSPITAL, Purnea, Bihar
Associate Professor, MGM Medical College, Kishanganj, Bihar
Executive Committee Member, Indian Foot & Ankle Society (IFAS)
Executive Committee Member, APOA Foot & Ankle Section
TALUS FRACTURE: Treatment Algorithm

2. • Second Largest Tarsal Bone.
• 60% Covered with Articular Cartilage.
• Parts: Head, Neck, Body, Latera Process,
Posterior Process.
• No Muscular attachments.
• Many Ligaments.
Talus: Anatomical Considerations

3. Anterior Tibial Artery
Posterior Tibial Artery
Artery to Sinus Tarsi
Perforating Branches
of Peroneal Artery
TALUS: Blood Supply

4. • Talus fractures frequently occur in a young, active, and mobile population.
• 5 to 7 % of foot fractures.
• History of high velocity injury present.
• Intense pain, unable to move ankle.
• Gross edema and ecchymosis usually present.
• When there is subluxation or dislocation the normal contours of ankle and hind
foot are distorted.
• Open injury not uncommon: Talar Extrusion!
TALUS FRACTURE: GENERAL CONSIDERATION

5. TALUS FRACTURE: DIAGNOSIS
XRAYS
• ANTEROPOSTERIOR VIEWS
• ANKLE MORTISE VIEW
• LATERAL VIEW
• CANALE VIEW

6. • Leg rotated internally 15° to
20°,aligning the intermalleolar line
parallel to the plate, 5th toe being
directly in line with the centre of the
calcaneum
• Internal rotation must be from the
hip; isolated rotation of the ankle will
result in a non diagnostic image.
• Foot in slight dorsiflexion.
TALUS FRACTURE: Ankle Mortise VIEW

7. • internal rotation of the plantigrade
foot by 15* on an x-ray film and
angling the beam at 75* to the
perpendicular.
• Gives best view of talus neck.
• Useful intraoperatively to check
alignment of neck
TALUS FRACTURE: CANALE AND KELLY VIEW

8. CT SCAN
• 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 alone.
TALUS FRACTURE: DIAGNOSIS

9. MRI SCAN
• Demonstrates osteonecrosis most
effectively.
• Use titanium screws, if AVN
anticipated in future.
TALUS FRACTURE: DIAGNOSIS

10. 1. Talar Neck Fracture
2. Talar Body Fracture
3. Talar Head Fracture
4. Lateral Process Fracture
5. Posterior Process Fracture
TALUS FRACTURE: ANATOMICAL CLASSIFICATION

11. • Constricted potion of bone between the body and the oval head .
• Directed forward, medial word, downward
• Angle of medial deviation 15 to 20 degree in adults
• Plantar deviation 24 degree approx
• Neck body angle 150 degree in adults
• Relatively thin diameter makes it weaker area and hence more vulnerable to
fractures
Neck of Talus: Anatomical Considerations

12. • Constitue 30 % of talus fractures.
• MECHANISM OF INJURY: Forced hyperdorsiflexion of
ankle and impingement of the talar neck on the distal
anterior tibia.
TALAR NECK FRACTURE

13. HAWKINS CLASSIFICATION: TALAR NECK FRACTURE
• Hawkins 1970 - talar neck fractures
into three type
• Canale and Kelly added type IV
• Based on displacement of body of
talus.
• Useful to predict long term outcome
and development
of AVN of talar body

14. HAWKINS TYPE 1
• Undisplaced fracture of
talar neck.
• Here medial blood supply
is still assured.

15. HAWKINS TYPE 2
• Displaced fracture of the talar neck
with subtalar dislocation or
subluxation.
• The medial blood supply may be
preserved.

16. • Displaced fracture of the talar neck with
dislocation or subluxation of the talar body
from both the tibiotalar and subtalar joints.
• All medial blood supply to the body is
disrupted
HAWKINS TYPE 3

17. HAWKINS TYPE 4
• Displaced fracture of the talar neck
with dislocation or subluxation of the
talonavicular, tibiotalar and subtalar
joints.
• Worst prognosis because of AVN of
the body and often of the head
fragment.

18. TREATMENT GOALS
1. Early anatomic reduction of the neck fracture
2. Reduction of dislocated joints
3. Stable fixation
4. Avoidance of complications

19. NON-OPERATIVE MANAGEMENT
Hawkins Type 1
• No displacement of the fracture.
• No incongruity of the subtalar joint.
CONFIRM with CT SCAN if in DOUBT

20. NON-OPERATIVE MANAGEMENT
• Below knee non weight bearing cast with ankle in
slight equinus for 1 month.
• Cast removed and short leg walking cast applied for
2 more months until clinical and x-ray signs of
healing appears.
• Once secure union is achieved, active range of
motion and progressive weight bearing as tolerated
is started.

21. NON-OPERATIVE MANAGEMENT
Hawkins Type 2: Closed Reduction
• Achieving closed reduction is very difficult.
• Should be only attempted if surgery is delayed.
• Therefore,ORIF is Treatment of Choice in most cases.

22. SURGICAL MANAGEMENT: Rationale
• Multiple attempts at closed reduction can increase the risk of
complications.
• Residual displacement of as little as 2 mm alter the contact
characteristics of the subtalar joint.
• Displacement of the fragments can cause skin tenting and necrosis.

23. • HAWKING Type 3 and 4 cannot be reduced and held by closed
method.
• Almost all require surgical stabilization.
• Most patients require additional surgery for relief of complications
resulting from the initial injury.
SURGICAL MANAGEMENT

24. SURGICAL MANAGEMENT: Approaches
• Anteromedial Approach
• Lateral Approach
• Posterior Approach
• Combined Approaches

25. SURGICAL MANAGEMENT: Anteromrdial Approach
• Most commonly used approach.
• Medial malleolar osteotomy if
required - Preserves the deltoid
ligament and thereby protects the
blood supply.

26. SURGICAL MANAGEMENT: Lateral Approach
• Lessens the chance of damage to the
blood supply.
• Howerver exposure of the lateral surface
of the talus and subtalar joint requires
extra caution to avoid injury to blood
vessel of the sinus tarsi.
• Facilitates visualization of subtalar joint.
• Poor exposure of # site.

27. • Screws directed from posterior to anterior.
• Screw placement perpendicular to the fracture line to achieve better
compression.
• Risk to neurovascular structure.
SURGICAL MANAGEMENT: Posterior Approach
SURGICAL MANAGEMENT: Combined Approaches
• Used when severe comminution present.
• Caution to be taken to protect the tenuous blood supply to the talar
body.

28. SURGICAL MANAGEMENT: Fixation Methods
A. Screw Fixation
• Anterior to Posterior
• Posterior to Anterior
B. Plate Fixation

29. Advantages Disadvantages
Direct visualization of fracture reduction Difficult to insert perpendicular to fracture line
Avoidance of articular cartilage damage
Less strong compared to posterior-to-
anterior screws and plate fixation
Use of compression screws where
indicated
Inappropriate use of compression may
cause malalignment, especially varus
Screw Placement: Anterior to Posterior

30. Advantages Disadvantages
Stronger fixation compared with anterior
screw fixation
Indirect visualization of reduction; may
require change in positioning
Easily inserted perpendicular to fracture line Some cartilage damage to posterior talus.
May cause less soft tissue disruption Risk of iatrogenic nerve damage
Screw Placement: Posterior to Anterior

31. Advantages Disadvantages
Strong fixation Extensive soft tissue dissection
Useful to buttress comminuted
columns
Risk of hardware prominence
TALAR NECK FRACTURES: Plate Fixation

32. 10 weeks Post-op
SURGICAL MANAGEMENT: Open #s

33. • AVN
• Malunion
• Nonunion
• Arthritis
TALAR NECK #S: COMPLICATIONS

34. COMPLICATIONS: Avascular Necrosis
• Most common complication of talar neck fracture.
• Extent of osteonecrosis directly related to degree of vascular disruption
Hawkins Sign: Subchondral Lucency
MRI

35. COMPLICATIONS: Avascular Necrosis
Precollapse:
• Modified Weight Bearing
• Patela tendon brace cast
• Compliance difficult
• Efficacy unknown
Postcollapse:
• Observation
• Arthrodesis if symptomatic

36. TALAR BODY FRACTURE
Fractures of the talar body are intraarticular injuries in which the articular
surfaces of the tibiotalar and the subtalar joints are involved.
In LATERAL XRAY VIEWS fractures extending into or posterior to the
lateral process of the talus are defined as talar body fractures (fractures
anterior to the lateral process are defined as talar neck fractures).

37. TALAR BODY FRACTURE: Treatment
OPERATIVE: As surface for fixation is always
articular, fixation is done by headless compression screw or
bioabsorbable pins.
SURGICAL APPROACH – Anteromedial Approach with
Medial Malleolus Osteotomy, or Lateral Approach, as
required by the Fracture geometry.

38. TALAR HEAD FRACTURE
• Incidence- 5 to 10 % of talar injuries.
• Mechanism of injury: Axially directed loading and compression of
talar head
• Injuries to calcaneocuboid and subtalar joint are common with these
injuries
Treatment PRINCIPLES
• Maintainance of alignment of dorsomedial arch of foot.
• Prevention of talonavicular joint incongruity and instability
• Reduction of displaced talar head fragment

39. TALAR HEAD FRACTURE: Treatment
Conservative: Undisplayed Fractures.
Surgery:
• Displaced fractures and those associated with joint subluxation
or dislocation.
• Small comminuted segments can be excised.
• Larger fragments are reduced with Herbert’s screws.

40. FRACTURE OF LATERAL PROCESS OF TALUS
Snowboarder’s fracture
OFTEN MISDIAGNOSED as
ANKLE SPRAIN
MECHANISM OF INJURY: Axial loading,
dorsiflexion, external rotation and eversion of
foot

41. FRACTURE OF LATERAL PROCESS OF TALUS
Type I fractures can be treated in a non weight-bearing cast for 6 weeks, unless
they are displaced or involve a significant portion of the talar side of the posterior
facet, in which case they should be treated by ORIF.
Type II fractures benefit from débridement of fracture fragments.
Type III fractures- treated conservatively with cast application.
If non union occurs debridement of fragments is advised.

42. POSTERIOR PROCESS FRACTURES
• These include the medial and lateral tubercle fractures.
• Fracture occurs in a severe ankle inversion injury where
posterior talofibular ligament avulses the lateral
tubercle.
• Undisplaced fracture treated with a short leg cast for 4
weeks.
• Displaced fracture treated with primary excision of small
fragments or ORIF when entire Posterior Process is
Involved.

43. • Have Good Understanding of Anatomy and Identify the fracture.
• Adequate Imaging and Proper Pre-op Planning including the timing of
Surgery.
• Look out for signs of Complications with timely intervention.
TAKE HOME MESSAGE
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