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Fracture talus
1.
2. In 1919, Anderson published a series of foot
injuries sustained by aviators in World War I
which he called Aviator's Astralagus.
He emphasized that the mechanism of injury
was excessive dorsiflexion of the foot as
pressure was applied to the rudder bar.
3. In 1952, Wildenauer gave a complete
description of the blood supply, which allowed
for a better understanding of the complications
of talus fractures.
In 1970, Hawkins developed a classification of
talus fractures, which provided guidelines for
treatment as well as the prognosis of different
fracture types
4. The talus is divided into the head, neck, and body,
and 2 processes, the posterior and the lateral.
The talus is shaped like a truncated cone and is
wider anteriorly than posteriorly,which creates
greater ankle stability in dorsiflexion.
The neck has approximately 15 ° to 20 ° of medial
deviation and is the area most vulnerable to
fractures.
5. There are no musculotendinous attachments to the
talus,the tendon of the flexor hallucis longus slides
within the groove formed by the medial and lateral
tubercles of the posterior process.
Nearly 70% of the entire surface area is articular
surface, which gives the talus a total of 7 articular
surfaces.
Because of the large amount of articular surface
and the lack of any musculotendinous attachments,
the talus is left with a tenuous blood supply.
8. calcaneal branches supplying the posterior
process
The artery to the tarsal canal supplying the head
and neck and
The deltoid branch supplying the neck and body
9. Artery to the tarsal sinus , which is the anterolateral
opening of the tarsal canal
This artery has several aborations supplying the
talar head and body before it forms an anastomotic
vascular loop with the artery of the tarsal canal
10. Several small branches joining the calcaneal
branches.
It also contributes to the anastomotic plexus of the
tarsal sinus by way of the penetrating peroneal
artery
11.
12.
13. Within the tarsal canal and the tarsal sinus the
critical anastomosis perforates the inferior neck to
form primary source of blood supply to the body of
the talus.
In talar neck fractures with increasing
displacement, the branches from the dorsalis
pedis artery as well as artery of the tarsal canal
and artery of the tarsal sinus can be disrupted.
14. So the rate of osteonecrosis depends upon
the degree of fracture displacement.
15. Talar Neck fractures-Hyper dorsiflexion
The neck of the talus impacts against the
leading edge of distal tibia.
Fracture of talar body-Axial Load
Lateral and posteromedial processes-Low energy
injuries.
Can result from inversion and eversion
mechanism.
16.
17. A high degree of suspicion is required for
detection of the talar process fractures. These
injuries can be difficult to appreciate on routine
radiographs.
In high energy talar fractures significant
compromise of the soft tissue envelop is common.
18. Association of dislocation with talar neck fracture
is common.
Emergency reduction of the dislocated talus is one
of the key principles in the management of the
fractures of the talus.
An accurate assessment of the vascular and
neurologic status of the foot is important.
19. Plain Radiographic views-
Standard Ap,Lateral and Mortise views.
Canale and Kelly view of the foot-
A view of the talar neck achieved by placing the
foot plantigrade on the x ray film and angling the
beam at 75degrees top the perpendicular.
Pronation and internal rotation of the foot helps to
visualise medial aspect of the neck.
20.
21. CT scans provoid better information than plain
radiographs.
MRI is useful for diagnosis of osteonecrosis
22. Emergency reduction of the dislocated joints,
urgent anatomic fracture reduction and
stabilization, maintaining an intact vascular
supply and soft tissue envelope provide the
best probability of regaining an excellent
functional result.
23. Hawkins Classification-
Type I-Vertical Fractures without displacement.
Type II-Displaced fractures with
subluxation/dislocation of the subtalar joint
Type III-displacement of body from both subtalar
and ankle joint.
Type IV-Similar to type III with dislocation of talar
head from the talonavicular joint.
24.
25. Non operative Management-
Only Type I fractures can be treated
nonoperatively.
Conformation of the anatomically maintained
reduction should be done with CT scan.
Non weight bearing in short leg cast for 8-12
weeks.
26. Type II fractures-To flex the knee followed by
plantar flexion of the foot.
Type III fractures-Plantar flexion and varus
positioning of foot
Transverse steinman pin may be required to be
passed through the calcaneus.
Direct pressure on the talar fragment may be
required to reduced fragments.
27. 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 sub talar joint.
Displacement of the fragments can cause skin
tenting and necrosis.
29. Most commonly used approach.
Fascilitate medial malleolar osteotomy if required.
Medial malleolar osteotomy preserves the deltoid
ligament and thereby protect the blood supply.
30.
31. This may lessen the chance of damage to the
blood supply.
Howerver exposure of the lateral surface of the
talus and sub talar joint requires extra caution to
avoid injury to blood vessel of the sinus tarsi.
Facilitates visualization of subtalar joint.
Facilitates placement of shoulder screw.
32.
33. The screws directed from posterior to anterior may
facilitate placement of screws perpendicular to the
fracture line and achieves compression lag screw.
The risk of neurovascular compromise present.
34. Used when severe comminution present.
Caution to be taken to protect the tenuous blood
supply to the talar body.
35. Anterior to posterior screw fixation
Posterior to anterior screw fixation
Direct plate fixation
36. Advantages Disadvantages
Direct visualisation of Difficult to insert
the fracture reduction perpendicular to
fracture
Avoidance of Less strong as
cartilage damage compared to posterior
to anterior
37. Advantages Disadantages
Stronger than anterior Indirect visualisation of
screw fixaion the fracture
Easley inserted Risk of iatrogenic nerve
perpendicular to damage.
fracture site
41. Treatment is extremely challenging
Avascular body of the talus acts as large
sequestrum.
Surgical debridement including talectomy may be
required as treatment
42. Type I- 0-13%
Type II- 20-50%
Type III- 80%
Hawkin’s sign-Subchondral resorption of bone
indication vascularity of the talar body.
Bone scan and MRI-3 weeks after the injury.
43. Patellar tendon bearing orthosis
Primary triple arthrodeisis
Total talectomy with tibia and calcaneal fusion
Subtalar fusion
Plantar fusion.
Blair fusion.
44.
45. Dorsal displacement of the distal fragment and
varus malunion are common.
Results in limitation of the dorsiflexion and painful
gait.
46. 46-69%
Subtalar joint most commonly involved.
Due to osteonecrosis, cartilage damage,
immobilisation and malalingement.
Treatment –Local analgesic infiltration,
Arthrodesis of the involved joints.
47. Sneppen classification-
Type I-Transcondral fractures
Type II-sagittal,coronal and horizontal shearing
fractures
Type III-Fractures of the posterior tubercle.
Type IV-Fractures of the lateral process
Type V-Crush fractures
48. ORIF with cortical screws.
Excision of the small fragments.
In highly selective cases primary artrodesis can be
done.
Weigh bearing is started after union of the
fracture.
49. By axial load applied to the talar head through
navicular bone
Principle of the treatment include maintenance of
the alingemnt of the dorsomedial arch of the foot
Preventing talonavicular joint incongruity and
instability.
50. Displaced fractures may be treated with ORIF with
minifragment screws.
Talonavicular arthritis is a common complication
which is treated with longitudinal arch support with
increased arch rigidity.
51. Hawkin’s classification-
Nonarticular chip ractures
Single large fragment involving the talofibular and
subtalar articulations
Communited fracture involving both articulations.
52. Undisplaced and reduced fractures are treated
with short leg cast immobilisation for 4-6 weeks.
Dispalced fractures with large fragments are
treated with ORIF with screw fixation.
53. This fracture is associated with subtalar
dislocations
Excision of the ununited or mal united fragments
seems to relive local irritation symptoms
