Talus Fractures
Abdullah T. Eissa
Objectives
Introduction
• Uncommon
• Year 1500 : Frx by Egyptian
• Year 1970 : Hawkins neck classification
• Year 1978 : Canale and Kelly and type IV
Incidence
• 0.1 – 0.85% of all frx
• 5-7% of foot frx
• 2nd of all tarsals
• Mostly falls from a height or sustains of forced dorsiflexion
• 50% neck frx
• 13-23% body frx
Anatomy
PARTS OF TALUS
1. HEAD
2. NECK
3. BODY
4. LATERAL PROCESS
5. POSTERIOR PROCESS
• No muscle or tendon attachments
Medial ligaments
Lateral ligaments
Anterior and posterior ligaments
BLOOD SUPPLY
1. EXTRAOSEOUS
2. INTERAOSSEOUS
EXTRAOSEOUS
INTERAOSSEOUS
Clinical evaluations
ATLS for high mechanism
Hx
• Ankle pain
• Young, active and mobile pt
• MOI
• PMH
• Smoker
• Allergy
Px
• Limited ROM with ??crepitus
• Tenderness, diffuse swelling and ecchymosis
• Ankle and hindfoot contours disruptions
• DNV
• ??Open
• Other Ortho and Non-Ortho injuries
Xrays
• AP
• Lateral
• Ankle mortise view
• Canale and Kelly view
CT Scan
• Detailed and excellent visualization
• Surgical planning
MRI
• AVN
Anatomical classification
■ Talar neck fractures
■ Talar head fractures
■ Talar body fractures
■ Lateral process fractures
■ Posterior process fractures
Neck
HAWKINS
Goals of treatment:
1. Early anatomic reduction
2. Soft tissue
3. Stable fixation
3. Avoidance of complications
Type I
• Conservative
• Short leg cast or boot for 8 to 12 weeks
• NWB for at least 6 wks
Type II-IV
• Immediate close reduction
Subtalar close reduction
• knee flexion and longitudinal foot traction
• “unlock” the calcaneus
• EX-fix
Surgical options
SCREW FIXATION:
1. Anterior to posterior
2. Posterior to Anterior
DIRECT PLATE FIXATION
Anterior-to-posterior screw fixation
• Advantages:
1. Direct visualization of fracture reduction
2. Avoidance of articular cartilage damage
• Disadvantages:
1.Less strong compared to posterior-to-anterior screws and plate
fixation
2.Inappropriate use of compression may cause malalignment,
especially varus
Posterior-to-anterior screw fixation
Advantages:
1. Stronger fixation compared with anterior screw fixation
2. Easily inserted perpendicular to fracture line
3. May cause less soft tissue disruption
Disadvantages:
4. Indirect visualization of reduction
5. Some cartilage damage to posterior talus.
6. Risk of iatrogenic nerve damage
Direct Plate Fixation
Advantages:
1. Strong fixation
2. More useful for the comminution
Disadvantages:
3. Extensive soft tissue dissection
4. Risk of hardware prominence
Approaches
• Anterolateral approach
• Anteromedial approach
• Anteromedial approach combined with medial malleolar osteotomy
Anteromedial approach
Anterolateral approach
SNEPPEN CLASSIFICATION
I- transchondral dome fractures;
II- shear fractures;
III- posterior tubercle fractures;
IV- lateral process fractures; and
V- crush fractures
Body
Müller AO/OTA Classification
• C1
Müller AO/OTA Classification
• C2
Müller AO/OTA Classification
• C3
Lateral process
• Snowboarder’s fracture
• MISDIAGNOSED OFTEN WITH
ANKLE SPRAIN
V sign
Anatomical classification of the lateral
process
type 1 fractures do not involved the articular surface
type 2 fractures involve the subtalar and talofibular joints
type 3 fractures have comminution
Hawkins for lateral process
• Posterior process
provocative test
• posteromedial tubercle fractures
• result from an avulsion of the posterior talotibial ligament or posterior deltoid
ligament
• posterolateral tubercle fractures
• result from an avulsion of the posterior talofibular ligament
Conservative management
• nondisplaced (< 2mm) lateral process fractures
• nondisplaced (< 2mm) posterior process fractures
• nondisplaced (< 2mm) talar head fractures
• nondisplaced (< 2mm) talar body fractures
Operative management
• displaced (> 2mm) lateral process fractures
• displaced (> 2mm) talar head fractures
• displaced (> 2mm) talar body fractures
• medial, lateral or posterior malleolar osteotomies may be necessary
• displaced (> 2mm) posteromedial process fractures
• may require osteotomies of posterior or medial malleoli to adequately reduce
the fragments
Indications of fragment excision
• comminuted lateral process fractures
• comminuted posterior process fractures
• non-unions of posterior process fractures
Complications
• AVN
• Malunion
• Nonunion
• Arthritis
Incidence of AVN
• I: 15 %
• II: 50 %
• III: 85 %
• IV: 100
HAWKIN’S SIGN
References
• Rockwood and Green’s Fractures in Adults
• Talus Fractures: Evaluation and Treatment. J Am Acad Orthop Surg
2001;9:114-127
• Orthobullets
• Master techniques, fracture 3rd edition
Thank you
