Talus Fractures

Bethany Gallagher, MD

Vanderbilt University

Core Curriculum V5
Outline:
Talar body,
Neck Fractures
head and process fractures
• Anatomy
• Incidence
Subtalar dislocations
• Classification
Imaging
• Management
Classification
• Outcomes
Management
• Complications

Core Curriculum V5
Anatomy
• Surface 60% cartilage
• Articulations with Tibial Plafond, Medial Malleolus, Lateral Malleolus,
Calcaneus, Navicular

Figure 65-18: Tornetta P, Ricci WM, eds. Rockwood and Green's Fractures in Adults, 9e. Philadelphia, PA.
Wolters Kluwer Health, Inc; 2019.

Core Curriculum V5
Anatomy
• Multiple Ligamentous Attachments
• Anterior talofibular ligament
• Posterior talofibular ligament
• Talocalcaneal ligaments
• Tarsal Sinus ligaments
• cervical ligament
• talocalcaneal interosseous ligament
• Deltoid ligament
• Anterior tibiotalar ligament
• Superficial posterior tibiotalar ligament
• Deep posterior tibiotalar ligament
• Dorsal talonavicular ligament

Figure 64-4 and 64-5: Tornetta P, Ricci WM, eds. Rockwood and Green's Fractures in Adults, 9e.
Philadelphia, PA. Wolters Kluwer Health, Inc; 2019..
Core Curriculum V5
Complex Vascular Supply
• Posterior Tibial Artery
(47%)
• Artery of Tarsal Canal
• Main Contributor
Talar Body
• Deltoid Branch
• Anterior Tibial Artery
• Artery Tarsal Sinus
• Perforating Peroneal
Arteries Image used with permission AO Foundation

Core Curriculum V5
Complex Vascular Supply

Image used with permission AO Foundation

Core Curriculum V5
Talar Neck Fractures

Core Curriculum V5
Incidence

• 2 % of all fractures
• Associated complications
• avascular necrosis
• post-traumatic arthritis
• malunion
Mechanism of Injury
• Hyperdorsiflexion of the foot
on the leg
• Neck of talus impinges against
anterior distal tibia, causing
neck fracture
• If force continues:
• Talar body dislocates posteromedial
• Rotates around deltoid ligament

Core Curriculum V5
Injury Mechanism

• Previously called “aviator’s

astragalus”

• Usually due to motor vehicle

accident or falls from height

• Approximately 50 % of patients
have multiple traumatic injuries
Imaging
• Multiple plain film
orientations:
• 3 views ankle
• Demonstrates joint congruity

Core Curriculum V5
Canale View
• Slight ankle plantarflexion
with knee bent to rest foot
on the table
• 15 degree pronation
• Xray Tube
• 15 degree from vertical
Canale View
• Outlines morphology talar
neck
Figure 65-11: Tornetta P, Ricci WM, eds. Rockwood and Green's Fractures in Adults, 9e.
• A True AP view talar neck Philadelphia, PA. Wolters Kluwer Health, Inc; 2019.

Core Curriculum V5
 CT Scan
• Most useful assessment tool for
surgical planning
• Confirms displacement
• Demonstrates subtalar joint
reduction, comminution,
osteochondral fractures/debris
Talar Neck Fracture
Classification
• Hawkins Fracture Classification
• Predictive of AVN rates
• Overall incidence 31%
• Anastomic sling formed between Artery Tarsal Canal and Artery Tarsal Sinus in
the tarsal canal
• Often injured in talar neck fractures
• More recent studies have shown decrease AVN rates possibly due to
improved surgical techniques

Core Curriculum V5
Hawkins 1
• Type I: undisplaced
• AVN rate 0 – 13 %

• Uncommon
• CT often demonstrates
malreduction and rotation
Image used with permission AO Foundation

Core Curriculum V5
Hawkins 2
• Displaced fracture with subtalar
subluxation / dislocation
• AVN 20 – 50 %
• Most common type
• Subdivided:
• 2A: Subluxation 0% AVN
• 2B: Dislocation 25% AVN

Image used with permission AO Foundation

Core Curriculum V5
Hawkins 3
• Subtalar and ankle joint dislocated
• AVN 50 – 100 %
• Talar body extrudes, usually around
deltoid ligament
• Closed reduction often unsuccessful
• Urgent open reduction required
• Clear interposed soft tissue
• Flexor tendons/posterior tibial tendon
incarcerated
• Use joysticks and distractor for reduction
• Carefully plan surgical incisions if Image used with permission AO Foundation
planning for delayed ORIF

Core Curriculum V5
Hawkins 4
• Incorporates talonavicular
subluxation
• AVN 100%
• Rare variant

Image used with permission AO Foundation

Core Curriculum V5
Hawkins Classification
• Predictor of outcomes
• AVN
• Malunion
• Varus malunion 25-30%
• Subtalar joint arthritis
• 50% subtalar arthritis

Core Curriculum V5
Goals of Management
• Immediate reduction of dislocated joints
• Skin tension
• Vascular compromise
• Anatomic fracture reduction
• Stable fixation
• Facilitate union
• Avoid complications

Core Curriculum V5
Treatment Plan
• Initial Presentation
• Nondisplaced fracture
• CT scan
• Splint immobilization
• Displaced
• Adequate sedation
• Attempt closed reduction
• Flex knee to relax gastrocs

• Be aware of the • Traction on plantar flexed forefoot to
realign head with body
skin/skin compromise
• Successful 30-60% • Varus/valgus correction as necessary
• Direct pressure on talar body

Core Curriculum V5
Treatment Plan
• Emergent OR
• Irreducible
• Open Fractures
• 20-38%
• Skin/Vascular Compromise
• Open reduction
• Definitive ORIF vs
Temporary External
Fixation Temporizing spanning external
• Plan incisions for definitive fixation with reduced talus fracture
management waiting until swelling decreases for
definitive ORIF
(no fixation in zone of surgical
incisions)
Core Curriculum V5
Treatment Plan
• Place in temporary splint once talar neck fracture
reduced
• Time to definitive fixation NOT related to increased
risk of AVN
• Wait for appropriate soft tissue envelope to reduce
complications
• Despite optimizing skin envelope risk of wound dehiscence,
skin necrosis, and infection 10%

Core Curriculum V5
Hawkins I Fracture
• Non Operative & Non-Weight-Bearing Cast
OR:
• Percutaneous screw fixation and early motion
• AP screws acceptable treatment/union
• Limited risk to surrounding structures
• PA screws
• Biomechanically superior
• Perpendicular to fracture line
• Increased risk to surrounding structures FHL/sural nerve

Core Curriculum V5
Hawkins II, III, and IV Fractures:
• Results dependent upon development of complications
• Osteonecrosis
• Malunion
• Arthritis

Core Curriculum V5
Surgical Treatment
• Achieve anatomic reduction
• Utilize dual incisions
• Maintain capsular soft-tissue insertions to protect
blood flow
• Allows for visualization and correction of medial talar
neck comminution
• Utilize osteotomies as necessary
• Take x-ray of uninjured side for morphology
comparison

Core Curriculum V5
1st Approach: Anteromedial
• Medial to Tib Ant
• Make incision more
posterior for talar body
fractures to facilitate
medial malleolar
osteotomy (if osteotomy
planned)

Core Curriculum V5
1st Approach: Anteromedial
• Provides view of neck alignment and medial
comminution
• Extend incision distally to talonavicular joint –
hardware is placed distal to proximal and needs to
be well countersunk to avoid impingement

Core Curriculum V5
Medial Malleolar Osteotomy
• Predrill and pretap malleolus
• Osteotomy aims just off the medial corner of mortise to facilitate interdigitation
• Align exit point into the joint to allow for maximum visualization
• Chevron, straight, or stepcut techniques
• Osteotome to crack cartilage helps avoid mortise malalignment
• Care when retracting and dissecting to leave deltoid INTACT

Reference with figures: Vallier HA, Nork SE, et al. Surgical treatment of talar body
fractures. J Bone Joint Surg 2004; Supp 1: 180-92; and 2003; 85-A: 1716-24

Core Curriculum V5
2nd Approach: Lateral
• Tip of Fibula Base of the 4th metatarsal
• Mobilize EDB as sleeve

Core Curriculum V5
2nd Approach: Lateral
• Visualizes Anterolateral alignment and subtalar
joint
• Allows for debridement of debris in subtalar joint
• Facilitates Placement of “Shoulder Screw” or
lateral plate

Core Curriculum V5
2 incisions: Skin bridge
• Narrow skin bridge but generally
well tolerated
• Be sure to not dissect the dorsal
capsular structures to the distal
neck /head

Core Curriculum V5
Fixation Options
• Stable Fixation to allow early motion is the goal
• Often a combination of mini-fragment plate
fixation and screw fixation
• Depends on fracture comminution and medial neck
shortening
• Consider fully-threaded screws medially to prevent
medial neck shortening and varus
• Lateral plating for buttress

Core Curriculum V5
Anterior Screw Fixation:
Screw fixation alone is acceptable for
non-comminuted fractures, but
consider adding a lateral plate if
there is comminution.
• Easy to insert under direct
visualization
• Countersink screw heads if
encroaching on articular surfaces
• No difference in strength of
countersinking vs headless screws
Plate Fixation:
• Very useful in comminuted
fractures:
• 2.0 or 2.4 mm plates
• Easiest to apply to lateral cortex –
impinge on medial side
• Provides a length stable construct
• Careful contouring of the lateral
plate to prevent subfibular/lateral
gutter impingement

Figure 65-12: Tornetta P, Ricci WM, eds. Rockwood and Green's

Fractures in Adults, 9e. Philadelphia, PA. Wolters Kluwer Health, Inc; 2019.
Treatment
• Post operative rehabilitation:
• Sample protocol:
• Initial immobilization, 2-6 weeks depending upon soft tissue injury and
patient factors, to prevent contractures and facilitate healing
• Non weight-bearing, Range of Motion therapy until 3 months or fracture
union

Core Curriculum V5
Complications

• AVN • Nonunion
• Malunion • Arthritis

Core Curriculum V5
 AVASCULAR
NECROSIS
• Rates with Hawkins Class
• Functional outcomes significantly
worse with AVN
• Early ORIF does not prevent development of AVN
• Can see revascularization without collapse in 34-
47% patients with radiographic osteonecrosis

Core Curriculum V5
AVN: Diagnosis
• Hawkins’ Sign: Xray
finding 6-8 weeks post
injury
• Presence of subchondral
lucency implies
revascularization
• Increased radiodensity
c/w Osteonecrosis has
been seen from 4wk-
6month after injury
AVN: Imaging

• Plain radiographs:
sclerosis common,
decreases with
revascularization
• MRI: very sensitive to
decreased vascularity

Figure 65-37: Tornetta P, Ricci WM, eds. Rockwood and Green's Fractures in
Adults, 9e. Philadelphia, PA. Wolters Kluwer Health, Inc; 2019.
AVN Treatment:
• Precollapse: • Postcollapse:
• Modified WB • Observation
• PTB cast • Hindfoot fusions are
• Compliance difficult option if symptomatic
• Efficacy unknown

Core Curriculum V5
AVN Surgical Treatment
• 10-50% patients with
AVN have collapse
• Surgical treatments
• Patient
age/comorbities
• Bone stock availability
• Degree and location of
arthrosis

Core Curriculum V5
Surgical Treatments
• Options
• Total talus prosthesis
• Total ankle arthroplasty
• Dependent on talar
bone stock health
• Hindfoot fusions
Malunion: Incidence
• Common: up to 40%

• Most often Varus

• Medial neck collapse and medial
column shortening
Malunion: Diagnosis
• Varus hindfoot,
midfoot supination on
clinical exam

• Dorsal malunion on
Xray
Clinical Effect of Malunion
• Malunion:
• More pain
• Lateral foot overload and ankle instability
• Less satisfaction
• Less ankle and subtalar motion
• Worse functional outcome

Core Curriculum V5
Malunion Correction
• Intact motion with minimal OA
• Talar neck osteotomy
• Calcaneus osteotomy
• Possible midfoot derotational osteotomy
• Tendo Achilles Lengthening
• May require triple arthrodesis in fixed
deformity with OA

Figures 65-42 and 65-43: Tornetta P, Ricci WM, eds. Rockwood and
Green's Fractures in Adults, 9e. Philadelphia, PA. Wolters Kluwer Health, Inc;
2019..
Core Curriculum V5
Post -Traumatic Arthritis
• Incidence of post-
traumatic arthritis
• 30-90 %
• Variations reported
in outcomes are
multifactorial
• Increases with
subtalar dislocation
Post-Traumatic Arthritis
• Most commonly involves Subtalar joint

• Rx: Arthrodesis

Core Curriculum V5
Talar Body Fractures

Core Curriculum V5
Talar Body Fractures
• Treatment strategy and
outcomes similar to
talar neck fractures
• Fracture extends
within or posterior to
the lateral process
• Medial or Lateral
Malleolar Osteotomy
frequently required for
visualization
Talar Body Fracture
Classification

Image used with permission AO Foundation

Core Curriculum V5
Talar Body Fracture
Management
• Shear • Compression
• Nondisplaced • Highly comminuted
• Non-op treatment with • Acute fusion
immobilization/nonwei
• Blair fusion
ghtbearing
• Strut from
• Displaced anterior tibia
• ORIF • Tibiocalcaneal fusion
• Countersink screws
• Headless
compression screws

Core Curriculum V5
Talar Body Fractures
• Be aware of threatened skin
from fracture fragments
• Use both lateral and medial
malleolar osteotomies/fractures
for visualization

Lateral Skin tenting

from lateral body
fragment

Core Curriculum V5
Talar Body Fracture
• Similar fracture fixation
principles as the talar neck
fracture
• Plate fixation in highly comminuted
fractures with impaction and bone
loss
• AVN rates and posttraumatic OA
rates increase with fracture
severity
• No significant difference in
posttraumatic OA and rates of
AVN when compared to talar
neck fractures

Core Curriculum V5
Talar Body Fractures
• May consider percutaneous
fixation in non-displaced
• Difficult Salvage

6wksNonCompliant

TTC Fusion

Core Curriculum V5
Osteochondral Injury

Core Curriculum V5
Osteochondral Injuries
• Frequently encountered with talus neck and body fractures
• Require small implants for fixation
• Excise if unstable and too small to fix

Core Curriculum V5
Osteochondral Injuries

Core Curriculum V5
 Osteochondral Fragment
Repair

Large fragment repaired, small fragment excised

Core Curriculum V5
Osteochondral Fragment Repair
• Counter-sink screw fixation
• Headless compression screws

Core Curriculum V5
Talar Head and Process
Fractures

Core Curriculum V5
Talar Head and Process
Fractures
• Treat according to injury
• Operate when associated with
joint subluxation, incongruity,
impingement or marked
displacement
• Fragments often too small to
fix and require excision

Core Curriculum V5
Talar Head Fracture
• Can be subtle
• CT demonstrates
subtalar injury and
subluxation

Figure 60-30: Tornetta P, Ricci WM, eds. Rockwood and Green's Fractures in Adults, 9e.
Philadelphia, PA. Wolters Kluwer Health, Inc; 2019.
Treatment of Talar Head
Fracture
• Requires 2 incisions to
debride subtalar joint
from lateral approach,
and reduce / stabilize
fracture from medial
side
• Consider bridge plating
across the fracture to
maintain length and
prevent collapse

Figure 60-30: Tornetta P, Ricci WM, eds. Rockwood and Green's Fractures
in Adults, 9e. Philadelphia, PA. Wolters Kluwer Health, Inc; 2019.

Core Curriculum V5
Lateral Talar Process Fractures
• “Snowboarder’s fracture”
• Mechanism: may occur from inversion (avulsion injury) or eversion
and axial loading (impaction fracture)
• Often misdiagnosed as “ankle sprain”
• Best results if treated early, either by immobilization, ORIF or
fragment excision
• If diagnosed late consider fragment excision as attempts to achieve
union often fail

Core Curriculum V5
Lateral Process Example
• Usually require CT scan
• Often excised due to size of fragments
• Difficult to achieve union

Core Curriculum V5
Lateral Process Fractures
• Can lead to subtalar OA and deformity through the subtalar joint
• Can also see cartilage damage of the posterior facet subtalar joint

Core Curriculum V5
Treatment Options
• Non-operatively for minimally displaced fractures

• Excision of fragment

• Isolated mini fragment screws

• Mini plate fixation

Core Curriculum V5
Mini Plate Procedure
1. Lateral approach
2. Subtalar chondral debris
removed
3. Impaction elevated if
present & filled with
allograft if required
4. Preliminary 0.45 Kirschner
wire (K-wire) fixation.
5. 2.0 mm “T” plate applied
upside down
6. Lag screw fixation -
avoiding overcompression
with comminution

Core Curriculum V5
Posterior Talar Process Fracture
• 2 components: medial and lateral tubercle
• Groove for FHL tendon separates the two tubercles
• Differentiate fracture from os trigonum – well corticated, smooth oval
or round structure

Figure 65-31: Tornetta P, Ricci WM, eds. Rockwood and Green's Fractures
in Adults, 9e. Philadelphia, PA. Wolters Kluwer Health, Inc; 2019. Core Curriculum V5
Posterior Talar Process
Fractures
• Medial tubercle fracture: “Cedell’s fracture”
• Lateral tubercle: “Shepherd’s fracture”

• Treatment: immobilize or excise or ORIF

• Use low profile fixation to prevent posterior impingement or FHL
tendon irritation

Core Curriculum V5
Treatment
• Usually associated with Talar Neck Fx
• Posteromedial Approach behind Neurovascular
Bundle
• Medial Malleolar Osteotomy – usually not effective
for exposure or fixation
• Significant displacement or nonunion can lead to
varus hindfoot as the subtalar joint subsides into
defect

Core Curriculum V5
Open Talar Body Extrusion
• Catastrophic Injury
• 60% Open injuries
• Infection Rates 25-50%
• Reinsert extruded bone
after thorough washing
• Maintain bone stock
• Maintain height
Subtalar Dislocations

• Spectrum of injuries

Relatively Innocent

Very Disabling
Classification

• Usually based upon

direction of dislocation:

• Medial dislocation: 85 %,
low energy
• Lateral dislocation: 15 %,
high energy
Other Important Considerations:
All have prognostic significance:
• Open vs Closed • Reducible by closed
means or requiring
open reduction
• High or low energy
mechanism
• Associated impaction
injuries
• Stable or unstable post
reduction

Core Curriculum V5
Important Distinction:
Pantalar dislocation vs Subtalar Dislocation

• Total talar dislocation, or pan

talar dislocation
• Results from continuation of
force causing subtalar
dislocation
• High risk of AVN, usually Open pantalar dislocation
open, poor prognosis with skin loss showing
Incongruent reduction:
Result was AVN and
pantalar fusion
Management of Subtalar
Dislocation
• Urgent Closed reduction:
• Adequate sedation
• Knee flexion
• Longitudinal foot traction
• Accentuate, then reverse deformity

• Successful in up to 90 % of patients

Core Curriculum V5
Anatomic Barriers for
Unsucessful Closed Reductions
Medial Dislocation Lateral Dislocation
• Peroneal Tendons • Posterior tibial tendon
• EDB • Flexor Hallucis Longus
• Talonavicular joint capsule • Flexor Digitorum Longus

Core Curriculum V5
Open Reduction: Lateral subtalar
dislocation with
interposed posterior
• More likely after high tibial tendon

energy injury
• More likely with lateral
dislocation Figure 65-51: Tornetta P, Ricci WM, eds. Rockwood

• Cause:
and Green's Fractures in Adults, 9e. Philadelphia, PA.
Wolters Kluwer Health, Inc; 2019.

• soft tissue interposition

(Tib post, FHL, extensor
tendons, capsule)
Use a small posteromedial
• bony impaction incision, retract interposed
soft tissue to reduce
between the talus and dislocation
navicular
Be sure to plan for any
necessary f/u surgical
incisions!!
Associated Fractures

Medial dislocation Lateral Dislocation

• Talar Head • Cuboid
• Posterior Process • Anterior process calcaneus
• Navicular • Fibula
• Posterior process

Core Curriculum V5
Rehabilitation:
• Stable injuries:
• 4 weeks immobilization
• Physical Therapy for mobilization
• Unstable injuries:
• Usually don’t require internal fixation once reduction achieved
• If necessary – external fixation or transarticular wire fixation

Core Curriculum V5
Outcome of Subtalar Dislocations:
• Less benign than previously
thought
• Subtalar arthritis:
• Up to 89 % radiographically
• Symptomatic in up to 63 %
• Ankle and midfoot arthritis
less common
Summary:
Talar body,
Neck Fractures
head and process fractures
• Anatomy
• Incidence
Subtalar dislocations
• Classification
Imaging
• Management
Classification
• Outcomes
Management
• Complications

Core Curriculum V5
Selected References
Hawkins LG 1970 Fractures of the neck of the talus. J Bone Joint Surg Am 52(5):991-1002.
Canale ST, Kelly FB, Jr. 1978 Fractures of the neck of the talus. Long-term evaluation of seventy-one
cases. J Bone Joint Surg Am 60(2):143-56.
•the two classics on talus fractures. Rates of AVN, classification, etc. Good descriptive papers.
Additional Clinical papers:
Metzger MJ, Levin JS, Clancy JT 1999 Talar neck fractures and rates of avascular necrosis. J Foot
Ankle Surg 38(2):154-62.
Whitaker C, Turvey B, Illical E. Current Concepts in Talar Neck Fracture Management. Curr Rev
Musculoskelet Med. 2018 Sep; 11(3): 456–474.
Vallier, Heather. Fractures of the Talus: State of the Art. J Orthop Trauma . 2015 Sep;29(9):385-92.
Romeo N, Hirschfeld A, Githens M, Benirschke S, Firoozabadi R. Significance of Lateral Process
Fractures Associated With Talar Neck and Body Fractures. J Orthop Trauma. . 2018 Dec;32(12):601-
606.

Core Curriculum V5
Selected References
Sanders DW, Busam M, Hattwick E, Edwards JR, McAndrew MP, Johnson KD. Functional outcomes following displaced talar neck
fractures. J Orthop Trauma 2004; 18: 265-270.
Vallier HA, Nork SE, Barei DP, Benirschke SK, Sangeorzan BJ. Talar neck fractures: results and outcomes. J Bone Joint Surg 2004;
86-A: 1616-1624.
Fleuriau Chateau PB, Brokaw DS, Jelen BA, Scheid DK, Weber TG. Plate fixation of talar neck fractures: preliminary review of a new
technique in twenty-three patients. J Orthop Trauma. 2002;16(4):213-9.
Vallier HA, Nork SE, et al. Surgical treatment of talar body fractures. J Bone Joint Surg 2004; Supp 1: 180-92; and 2003; 85-A:
1716-24
Bibbo C, Anderson R, Marsh WH. Injury characteristics and the clinical outcome of subtalar dislocations: a clinical and
radiographic analysis of 25 cases. Foot ankle int 2003: 24: 158-63.

Clare M, Maloney P. Prevention of Avascular Necrosis with Fractures of the Talar Neck. Foot Ankle Clin. 2019 Mar;24(1):47-56.

Dodd A, Lefaivre K. Neck Fractures: A Systematic Review and Meta-analysis. J Orthop Trauma. 2015 May;29(5):210-5.
Jordan R, Bafna K, Liu J, Ebrahein N. Complications of Talar Neck Fractures by Hawkins Classification: A Systematic Review. J Foot
Ankle Surg. Jul-Aug 2017;56(4):817-821.

Beltran M, Mitchell P, Collinge C. Posterior to Anteriorly Directed Screws for Management of Talar Neck Fractures. Foot Ankle Int.
2016 Oct;37(10):1130-1136.

Core Curriculum V5
Selected References
Lee C, Brodke D, Perdue P, Patel T. Talus Fractures: Evaluation and Treatment. J Am Acad Orthop Surg. 2020 Oct
15;28(20):e878-e887.

Thordarson DB. Talar body fractures. Orthop Clin North Am. 2001 Jan;32(1):65-77, viii

Tornetta P, Ricci WM, eds. Rockwood and Green's Fractures in Adults, 9e. Philadelphia, PA. Wolters Kluwer Health, Inc; 2019.

Core Curriculum V5