Talar FracturesD. N. Bid

Definition • #s of the hind foot are those involving the

calcaneus and the talus.• #s of the talus include #s of the talar neck, the

talar body, or the talar head, as well as osteochondral #s and #s of the lateral process.

• (Figs. 31-1, 2, 4, and 7.)

2

3

4

Fig.31-3

# of the talar neck treated with ORIF. After surgery, the patient initially had a bulky compressive dressing. The # was placed in a cast after the edema subsided. Talar #s tend to have less swelling than calcaneal #s.

5

6

7

Mechanism of Injury• #s of the body and neck of the talus usually

result from high energy injuries such as motor vehicle accidents.

• #s of the head and posterior aspects of the talus usually result from axial load.

• Osteochondral #s and lateral process #s are often seen with ankle or subtalar sprains and #/dislocations of the subtalar joint.

8

TREATMENT GOALS

• Orthopedic Objectives– Alignment Anatomic realignment is more critical for the articular

surfaces of the talus than for any other bone in the foot. This is because of the high risk of avascular necrosis due to a poor blood supply.

– Stability Stable fixation of talar neck #s is crucial to reduce the risk

of avascular necrosis of the talar head. #s of the talar body must be stably fixed to restore subtalar joint congruity. #s of the talar head must be stably maintained to allow for load transfer across the talonavicular joint.

9

10

TREATMENT GOALS

• Rehabilitation Objectives– ROM – Restore ROM of the ankle and foot in all planes.– Restore the full ROM of the subtalar joint.– Intraarticular #s of the talar body involving the subtalar joint may have residual loss of ROM. This causes increased stress on the subtalar articulation and leads to further degeneration and arthritic changes.

11

Table 31-1. Ankle Range of Motion

Motion Normal Functional

Ankle Plantar Flexion

45 20

Ankle dorsiflexion 20 10

Foot Inversion 35 10

Foot Eversion 25 10

dnbid 12

– Muscle Strength Strengthen the muscles of the foot. Invertors of the foot Evertors of the foot Dorsiflexors of the foot

Plantar flexors of the ankle & foot

13

– Functional Goals Normalize the gait pattern.

14

15

• EXPECTED TIME OF BONE HEALING– Six to 10 weeks.

• EXPECTED DURATION OF REHABILITATION• 12 to 16 weeks.• Patients in whom avascular necrosis develops usually

need further surgery and extensive rehab for up to 12 months.

dnbid 16

Methods of Treatment

• ORIF (Multiple Screws)– Biomechanics: stress shielding device with rigid

fixation.

– Mode of bone healing: Primary, without callus formation.

– Indications: Displaced #s of the talus. (Figs. 31-2, 3, 4, 5, 6, 7, 8, 9 &10).

17

• Cast– Biomechanics: Stress sharing device.– Mode of bone healing: Secondary, with callus formation. This

mainly cancellous bone shows only a small amount of callous because of the cortex is quite thin and there is minimal periosteum.

– Indications: A nondisplaced or minimally displaced # of the talar neck may be anatomically reduced with a closed technique and then placed in a cast.

A problem with this method is that maintaining the patient in a cast precludes the early motion important for successful rehab of the tibiotalar and subtalar joints.

In general , casting as a primary form of treatment should be considered a temporary and not an acceptable final method of treatment.

18

SPECIAL CONSIDERATIONS OF THE FRACTURE• AGE

• ARTICULAR INVOLVEMENT

• LOCATION

• OPEN #S

• TENDON & LIGAMENTOUS INJURIES

19

ASSOCIATED INJURIES

• Because of the large magnitude of the force involved with most of the these #s, there can be significant soft-tissue damage secondary to swelling.

• Even with open #s, isolated compartments may still swell and need to be observed .

• The patient must be watched carefully for the development of foot compartment syndrome.

20

Weight Bearing

• #s of talus are initially placed in a bulky compressive dressing or cast with the foot elevated for 2-5 days.

• When a walking cast is applied, the patient may be allowed wt-bearing (wt of leg) if the fixation can tolerate it.

• It is very important with talar #s for the patient to keep the foot elevated as much as possible in the first 3 weeks to optimize circulation to the talus, in the hope of preventing avascular necrosis (Figs. 31-11 & 12).

21

22

23

• In the dependent position, there is inadequate venous return secondary to the vascular congestion caused by the swelling.

• Early motion is extremely important for a satisfactory final outcome, and the patient with rigid internal screw fixation frequently is put in a bivalve cast or removable cam walker ( a rigid, padded, supportive splint with a rocker bottom) 2 weeks after surgery to expedite exercise of the joints.

• The patient should ideally remain partial wt-bearing for up to 3 months and then progress with wt-bearing as tolerance and radiographic evidence of healing suggest.

24

Gait

• Stance Phase– Heel Strike– Foot Flat– Mid-Stance– Push-Off

• Swing Phase

25

TREATMENT

• EARLY TO IMMEDIATE (Day of Injury to One Week)

• Bone Healing

26

Prescription

DAY ONE TO ONE WEEK

27

TWO WEEKS

• BONE HEALING

28

Prescription

TWO WEEKS

29

FOUR TO SIX WEEKS

• BONE HEALING

30

Prescription

FOUR TO SIX WEEKS

31

SIX TO EIGHT WEEKS

• BONE HEALING

32

PRESCRIPTION

SIX TO EIGHT WEEKS

33

EIGHT TO TWELVE WEEKS

• BONE HEALING

34

PRESCRIPTION

EIGHT TO TWELVE WEEKS

35

LONG TERM CONSIDERATIONS AND PROBLEMS

36

The End

37