Fracture Talus

Dr.Jayant Sharma.M.S, DNB, MNAMSCONSULTANT ORTHOPADICS

AND SPORTS MEDICINE.

www.drjayantsharma.com

TALUS IInd most common tarsal

fracture

60% coverage by articular cartilage

no tendon / muscle attachmentsTenuous blood supply

90% of motion of foot / ankle

Body, neck, head, lat. and post. processes

Blood supply

Branches from post. and ant. tibial arteries,

Perforating peroneal arteries

Anastomoses in sinus tarsi and tarsal canal

inferior sling Capsular and

ligamentous supply

FracturesFractures

Head Head Neck – 50%Neck – 50% BodyBody ±±

DislocationDislocation Lat processLat process Post Tab Post Tab

IssuesIssues How to diagnose How to diagnose ReductionReduction Lat process and post tubLat process and post tub Osteochondral fractureOsteochondral fracture Vascular complicationVascular complication Avascular necrosisAvascular necrosis

HOW TO DIAGNOSE?HOW TO DIAGNOSE? X-ray – AP / Mortice

(enlocated / assoc #) - Lateral (#, subtalar

joint) - Neck view (Canale

& Kelly) CT – comminution,

alignment, subluxation

Talar neck fracture Mechanism – hyperdorsiflexion or direct

axialload e.g MVA, fall from height, “aviators astragalus”

Posterior capsule ruptures , talar neck impacts on distal tibia , vertical fracture.

Foot subluxes forwards > talar body in equinus.

Or Pushed postero-medially out of mortice

sits between medial malleolus and tendo Achilles.

Talar neck fracture

Osteonecrosis depends on degree Osteonecrosis depends on degree ofofdisplacement.displacement.

Undisplaced disrupt intra-Undisplaced disrupt intra-osseous branches of sinus tarsi / osseous branches of sinus tarsi / tarsal canal arteriestarsal canal arteriesbut major sling remains intact.but major sling remains intact.

If Displaced above -- disrupt If Displaced above -- disrupt dorsalis pedis branches to neck.dorsalis pedis branches to neck.

Talar neck fracture

Classification Hawkins’

classification (1970) I – undisplaced

vertical fracture II – displaced fracture

and dislocated S.T. jt. III – above +

dislocated ankle joint IV – above +

dislocated talo-navicular joint

(Canale & Kelly, Khazim & Salo)

Associated fractures - 64% (Hawkins, Lorentzen) Medial malleolus. 19-28% Calcaneum. 10% Metatarsal fractures. Distal tibio-fibular joint diastasis.

Talar neck fracture

Treatment Best results with

prompt, accurate anatomical

reduction & maintenance

Type I – absolutely no displacement / ST

incongruency BK cast 6 -12 weeks

(NWB 6 weeks)

Talar neck fracture

Treatment Type II – prompt

closed reduction, traction, plantarflexion,

correct varus /valgus Xray – in equinus BK cast in equinus

(6weeks), cast for up to

3 months & 2 weekly Internal fixation

(antegrade fixation)

Type II Talar neck Fracture

Treatment Avoid multiple attempts

at closed reduction. Open reduction - Antero-medial or antero-

lateral approach Cannulated screws (4.5/

6.5 mm) (titanium)retrograde or antegrade– beware penetration

talo-navicular joint NWB cast 6-12 weeks

Talar neck fracture

TreatmentTreatment Type IIIType III – 25% open – 25% open Closed – prompt reduction, closedClosed – prompt reduction, closed reduction often impossiblereduction often impossible ?Arthroscopic assisted reduction?Arthroscopic assisted reduction Open reduction – postero-medial or Open reduction – postero-medial or

anteromedialanteromedial approachapproach Leave deltoid ligament fibres intactLeave deltoid ligament fibres intact Osteotomise / fractured medial malleolusOsteotomise / fractured medial malleolus

Internal fixation –Internal fixation – cannulated compressioncannulated compression screws (avoidscrews (avoidcomminuted medial neck)comminuted medial neck) Delayed primary closureDelayed primary closure at 5-7 daysat 5-7 days BK castBK cast NWB 3 months NWB 3 months

TreatmentTreatment

Treatment Type IV –manage as forIII, and reducetalo-navicular

joint(usuallyheals in cast) Prognosis relatedto displacement of

body

Talar Neck Fracture

Fractures Fractures neck with neck with subtalar subtalar

dislocation dislocation and post and post

dislocation of dislocation of Talus Talus Emergency Emergency Immediate Immediate Reduction Reduction

1942 –1942 – Boyd Boyd & & Knight – Red and Knight – Red and ST ArthrodesisST Arthrodesis1957 -1957 - BohlerBohler – – Open reduction If Open reduction If close Red fails-close Red fails-1959 -1959 - AllgowerAllgower – – open red and lag open red and lag screw screw 1962 -1962 - WatsonWatson Jones Jones –open –open reduction If close reduction If close Red failsRed fails1963 -1963 - Mc KeeverMc Keever Red and Triple Red and Triple ArthrodesisArthrodesis

Posterior displacement of body Posterior displacement of body needs open reductionneeds open reduction

Points to Points to rememberremember

ORIF may not ORIF may not be easy. Be be easy. Be

prepared to do prepared to do medial medial

Malleolus Malleolus OsteotomyOsteotomy – use – use of Calcaneal pin of Calcaneal pin Save Talus – Be Save Talus – Be

prepared to prepared to face AVNface AVN

Talar neck fracture – Complications

Skin Necrosis and Infection Prompt reduction, debride the open

wounds and leave open. Persisting infection > radical

debridement ofbody. Best results from excision of

sequestered talusand tibio-calcaneal fusion.

Talar neck fractureTalar neck fracture Malunion Varus – lateral weight bearing Subtalar joint stress secondary arthritis (osteotomy and bone graft) – Dorsal displacement of head -- reduced

dorsiflexion,pain (excise dorsal talar beak) Delayed Union / Non-union Delayed union common, but Non-union rare (0-

4%) Poor blood supply, limited periosteum on neck No healing at 12 months > Cortico-cancellous

bone graft

Blair Fusion-- Blair Fusion-- AdvantagesAdvantages Position of foot unchangedPosition of foot unchanged Backward displacement not Backward displacement not required required

Foot & Ankle relationship Foot & Ankle relationship not disturbed not disturbed

Limb not shortenedLimb not shortened Preserves some Sub- Talar Preserves some Sub- Talar MotionMotion

Talar neck fractureComplications-

Osteonecrosis Degree varies with

injury, but still need early, accurate reduction to reduce its

secondary effects. Type I : 0-13% Type II : 20-50 % Type III : 83-100%

X-ray – increased radio-density talar body

Later – collapse of subchondral bone, reduced joint space, fragmentation of body

MRI clearly defines presence and extent of involvement.

Talar neck fracture -Osteonecrosis

Talar neck fracture -Osteonecrosis

“Hawkins’ sign” – high sensivity, moderate specificity.

At 6-8 weeks, disuse atrophy because NWB. AP X-ray- subchondral

atrophy in dome, implying

vascularity

Talar neck fracture - Osteonecrosis

Primary goal is union, which still occurs, therefore continue NWB, even if no

Hawkins sign. Once united, still need up to 3 years

before revascularisation /PTB brace/NWB If dome collapse and pain, identify joint/s involved and arthrodese. Usually tibiotalocalcaneal fusion.

Talar body fracture

20% talar fractures Classification - Sneppen (1977) I - Osteochondral dome fracture II – Coronal, sagittal, horizontal

Shear fractures III – Posterior process fractures IV – Lateral process fractures V – Crush fractures

1% talar fractures Mechanism: – dorsiflexion / inversion anterolateral

lesion – plantarflexion / inversion

posteromedial lesion Often not visible on Xray > persistent

pain weeks after “sprain” +/- locking Bone Scan - sensitive, but not specific MRI – identification and classification

Osteochondral Dome Fracture

- Classification Anderson (1989) I – subchondral trabecular compression II – incomplete separation of fragment IIa – subchondral cyst III – fragment not attached, but remains in normal position IV – displaced fragment loose within joint Pritsch arthroscopic grading of cartilage condition (firm, soft, frayed)

Osteochondral Dome Fracture

Osteochondral Dome Osteochondral Dome FractureFractureTreatment Incidental finding at ORIF > remove or fix Incidental finding on Xray > observe Symptomatic – Stage I / II - BK cast 6 - 12 weeks NWB – If still symptomatic > soft > leave NWB

or drill cartilage frayed > debride & curette – If >1 cm and subchondral bone fix with

absorbable pin

Osteochondral Dome Osteochondral Dome FractureFracture --TreatmentTreatment Stage IIIStage III – prolonged NWB versus early surgery – prolonged NWB versus early surgery - Arthroscopy > debride fragment & curette - Arthroscopy > debride fragment & curette

underlying bedunderlying bed Stage IVStage IV – remove loose body, if bed covered by – remove loose body, if bed covered by fibrocartilage > leave, if frayed debride tofibrocartilage > leave, if frayed debride to bleeding subchondral bone / mosaicplastybleeding subchondral bone / mosaicplasty Results - 50% have pain on activity Results - 50% have pain on activity (Pettine & Morrey, Angermann & Jensen)(Pettine & Morrey, Angermann & Jensen)

Shear Fractures of BodyShear Fractures of Body

Fracture line extends into dome, Fracture line extends into dome, oror

into subtalar joint.into subtalar joint. MVA, fall from height. MVA, fall from height. Generally Generally

poor long-term results. Higher poor long-term results. Higher risk of osteonecrosis.risk of osteonecrosis.

AP / lateral / mortice / CTAP / lateral / mortice / CT Undisplaced Undisplaced -- BK cast until -- BK cast until

radiolradiol signs of healingsigns of healing Thordarson (2001)Thordarson (2001) > 1mm+ > 1mm+ displacement -- ORIF via medialdisplacement -- ORIF via medial malleolar osteotomymalleolar osteotomy ComplicationsComplications > osteonecrosis – > osteonecrosis –

NWB up to 2 years, arthritis 75%NWB up to 2 years, arthritis 75%

Lateral Process FractureLateral Process Fracture Snowboarder’s FractureSnowboarder’s Fracture

25% talar fractures25% talar fractures May extend into subtalar joint (bigger May extend into subtalar joint (bigger

fragments)fragments) Mechanism – dorsiflexion and inversionMechanism – dorsiflexion and inversion.. AP / mortice / CTAP / mortice / CT UndisplacedUndisplaced – BK cast NWB 6 weeks – BK cast NWB 6 weeks DisplacedDisplaced >2mm / 1cm fragment > ORIF >2mm / 1cm fragment > ORIF PrognosisPrognosis – often present with nonunion or – often present with nonunion or

arthritis months after injury. Best results with arthritis months after injury. Best results with undisplaced fracture or accurat reduction. May undisplaced fracture or accurat reduction. May need late excision of non-united fragmentsneed late excision of non-united fragments

or subtalar fusionor subtalar fusion

Posterior Process Posterior Process FractureFracture.. Lateral tubercle fractureLateral tubercle fracture

– – Mechanism :Mechanism : inversion inversion

or compressionor compression (extreme equinus)(extreme equinus) – – DDx: os trigonumDDx: os trigonum – – Xray : lateral, Bone ScanXray : lateral, Bone Scan – – TreatmentTreatment : undisplaced : undisplaced

– BK cast 4-6 weeks– BK cast 4-6 weeks – – Persistent pain and Persistent pain and

stiffness – excise non-stiffness – excise non-unitedunited

fragmentfragment

Posterior Process Posterior Process FractureFracture Medial tubercle fracture Medial tubercle fracture – – Rare, pronation in dorsiflexion (athletes)Rare, pronation in dorsiflexion (athletes) – – Present late with medial pain and Present late with medial pain and

swellingswelling – – Xray : lateral, avulsed medial fragment Xray : lateral, avulsed medial fragment

on APon AP – – Undisplaced : BK cast 6 weeksUndisplaced : BK cast 6 weeks – – Displaced : ORIF especially if ST jointDisplaced : ORIF especially if ST joint involved.involved. – – Non-union : persistent pain > excise Non-union : persistent pain > excise

fragmentsfragments

Crush fractureCrush fracture Uncommon, high complication rate.Uncommon, high complication rate. Usually significant displacement, and subluxed Usually significant displacement, and subluxed

subtalar /subtalar / ankle jointsankle joints C. TC. T Treatment :Treatment : anatomical reduction via anteromedial anatomical reduction via anteromedial arthrotomy +/- osteotomy medial malleolus, pins / arthrotomy +/- osteotomy medial malleolus, pins /

screwsscrews for large articular fragments. Bone graft / for large articular fragments. Bone graft /

substitute.substitute. If stable fixation, early ROM post-opIf stable fixation, early ROM post-op Complications Complications : osteonecrosis, arthritis, malunion: osteonecrosis, arthritis, malunion

Fractured Head of Fractured Head of TalusTalus Uncommon. Uncommon. Usually involves talo-Usually involves talo-

navicular joint.navicular joint. Mechanism : Mechanism :

compression ofcompression of head, plantarflexed head, plantarflexed

foot.foot. Xray : AP / lateral / Xray : AP / lateral /

oblique –oblique – check navicular and check navicular and

calcaneo-cuboid joint.calcaneo-cuboid joint.

Fractured Head of Talus -Fractured Head of Talus -TreatmentTreatment UndisplacedUndisplaced : BK cast NWB 6 - 12 weeks, then : BK cast NWB 6 - 12 weeks, then medial arch support 3-6 monthsmedial arch support 3-6 months Displaced : anatomical reduction via Displaced : anatomical reduction via

anteromedialanteromedial approach. Excise comminuted fragments.approach. Excise comminuted fragments. Complications Complications : persisting subluxation and: persisting subluxation and arthritis.arthritis. Talo-navicular pain may improve withTalo-navicular pain may improve with firm longitudinal arch support.firm longitudinal arch support. If fails, then arthrodesis talonavicular joint orIf fails, then arthrodesis talonavicular joint or entire midfoot (test with local anaes. injections)entire midfoot (test with local anaes. injections)

Association with Association with Fracture Fracture calcanceumcalcanceum Talus may be Talus may be

subluxated or subluxated or fractured along fractured along

with fracture with fracture calcanceum - a calcanceum - a very rare injuryvery rare injury..

Total Total TalectomyTalectomy

Tibio Tibio Calcaneal Calcaneal Fusion Fusion

Points to Points to RememberRemember Earlier the reduction the better are Earlier the reduction the better are

the chances of success the chances of success Subtalar subluxation and dislocation Subtalar subluxation and dislocation

should not be missedshould not be missed Deforming force is the key to Deforming force is the key to

reductionreduction Do not hesitate to put calcaneal pin Do not hesitate to put calcaneal pin Immobilisation for longer period Immobilisation for longer period Appreciate the jeopardised blood Appreciate the jeopardised blood

supply the footsupply the footTreat As Emergency Treat As Emergency

Recognise the Collapse of talus Recognise the Collapse of talus BLAIR fusion is the Best. BLAIR fusion is the Best. Tibio calcaneal fusion to be Tibio calcaneal fusion to be undertaken as a last resortundertaken as a last resort

Rare fractures to be kept in Rare fractures to be kept in mind mind