Talus can be subdivided into the head and neck, and body. Eleven of the fifty-seven fractures were open. Complications, secondary procedures, and the ability to return to work were evaluated at a minimum of one year. Branches from the dorsalis pedis supply the talar head and most of the dorsal talar neck. The deltoid branches are important to supply blood to the medial talar neck and talar body. Inokuchi S, Ogawa K, Usami N. Classification of fractures of the talus: Clear differentiation between neck and body fractures. Sometimes patients may present with neglected fractures or after native treatment with traditional bone setters. Patients will be unable to bear weight on the affected foot. Postoperatively, the patient is placed in a splint for 2 weeks. Comparison of plate and screw fixation and screw fixation alone in a comminuted talar neck fracture model. Some of the most common long-term complications after talar fractures are arthritis and a condition called avascular necrosis (AVN) of the talus. The ankle and subtalar joint are then put through a range of motion to ensure no plate impingement is occurring. Unauthorized use of these marks is strictly prohibited. Assessment of the soft tissue envelope should guide the foot and ankle surgeon to the appropriate time for fracture reduction [Figure 3]. Exposure from the medial side alone runs the risk of shortening the neck and malreducing the fracture. Organize in-house training events for your surgical staff, Hand Distal phalanges revision published. A Type I fracture is a shear injury in the coronal or sagittal plane, compared to the Type II fracture which involves the horizontal plane. On the other hand, Sakaki et al. It is important to distinguish between talar neck fractures and talar body fractures because the treatments and prognosis differ.13 If the fracture involves the talar dome or lateral process, then the fracture by default involves the talar body. Every break has a unique fracture pattern, so surgery requires its own tailored approach. 2-A, 2-B, 2-C, 2-D, 2-E, 2-F, and 2-G) 1-3. In their series, they found the most common body fractures were dome compression (26%) followed by the lateral process (24%), and posterior tubercle (21%). Before Your surgeon will then make one or two incisions over the bone on either side of the foot. Treatment is emergent reduction of the talus following by internal fixation in an acute or delayed fashion. This ensures the maintenance of both reduction and alignment of the plate. Dodd A, Simon D, Wilkinson R. Arthroscopically assisted transfibular talar dome fixation with a headless screw. The PubMed wordmark and PubMed logo are registered trademarks of the U.S. Department of Health and Human Services (HHS). The neck of the talus receives branches from the medial and lateral side. The predominantly extraosseous vascular supply of the talus predisposes it to significant injury in the setting of trauma. This site needs JavaScript to work properly. X-ray anteroposterior and lateral views of ankle (a) and CT scan sagittal cut of ankle (b) showing posterior talar body process fracture Sneppens type III (c) X-ray anteroposterior and lateral views of ankle showing that it needed posterior approach and fixation. Associated soft-tissue injury can occur, especially with increasing severity. This, however, is unusual as most talar neck fractures present with at least some displacement.CT examination is very helpful whenever there is any question about displacement, or requirement for debridement of the subtalar joint. Once bony union has been achieved, graduated weight-bearing can commence.Patients with talar neck fractures should not begin weight bearing as long as there is pain at the fracture site. Fractures of talar body are uncommon injuries often associated with fractures of other long bones and in polytraumatized patients. Tricortical segments held with screws are subject to rotational forces and may fracture at the time of drilling or screw insertion and risk loss of structural integrity. The clear majority of fractures require operative treatment. Ebraheim NA, Mekhail AO, Salpietro BJ, Mermer MJ, Jackson WT. Vallier HA. Gelberman RH, Mortensen WW. Commonly, motor vehicle crashes cause the foot to be axially loaded with the foot plate of the car impacting a dorsiflexed foot on the brake pedal. The incidence and severity of these complications are related to several factors including the intrinsic talar vascular supply, the initial extent of displacement, the presence of associated dislocation and the adequacy of reduction.28 This associated with the fact that more weight per area is borne by the talar dome than any other joint in the body means that posttraumatic arthritis and long standing disability are frequent complications to fractures of the talus.29 Even with accurate and appropriate surgical care morbidity is common. To avoid cutting the branches of the superficial peroneal nerve, most of the incisions must be made in a longitudinal direction. The indication and use of plates in fixation of talus fractures are reviewed. Therefore, the lateral side of the neck comes under tension and the medial side under compression. Open Talar Neck Fracture With Medial Subtalar Joint Dislocation: A Case Report. A medially placed distractor or external fixator may aid in direct visualization of the articular reductions. If severe comminution is present, fully threaded wires may be used to prevent shortening. On a good lateral view, there will be a single shadow of the superior convexity of the talar body, meaning the lateral and the medial sides of the talar dome are collinear. Your talus joins with your tibia and fibula (lower leg bones) to form your ankle joint. CT scans are often necessary. It is advisable to inspect the open wounds in the operating room. Hence, the patients with these injuries should be explained on the long term complications, and that secondary osteoarthritis is expected in displaced talar body fractures inspite of accurate reduction with stable fixation Table 4. What if I develop avascular necrosis of the talus?Avascular necrosis (AVN) of the talus can be a serious complication of fractures of the talus. A talus fracture is a break in this bone. After surgery, a posterior splint with the foot in neutral position is applied. You typically will be on crutches, putting no weight on the injured foot for 8-12 weeks after surgery until X-rays show that the fracture has healed sufficiently. It is the larger fragments and those with comminution that benefit from plate fixation. Jorgensen NB, Lutz M. Arthroscopic treatment of talar body fractures. in their series reported 88% union rates in their patients with Talar body fractures.16, The consequences following talar body fractures are dictated by the intensity of the initial injury, fracture comminution associated subtalar dislocation and the standard of reduction and internal fixation. The peroneal artery has branches laterally. Table 1 - The Hawkins Classification of Talar Fractures Management Management of talar neck fractures is dependent on their Hawkins classification. Eleven of the fifty-seven fractures were open. Regardless of the talar fracture location, there is a high association of adjacent fracture or disruption of the talar articulations in all three main anatomic types of talar fracture. Commonly, motor vehicle crashes cause the foot to be axially loaded with the foot plate of the car impacting a dorsiflexed foot on the brake pedal. K-wires and screws ranging from 2.0, 2.4, 2.7, and 3.5 mm diameter as well as 2.0 and 2.4 plates should be available. If closed reduction fails and must be performed in open fashion, a CT may be of benefit before reduction in the operating room. Anatomic reduction is critical, as varus malalignment results in marked decrease in subtalar motion as the hindfoot is locked in an inverted position.16 Talar neck malalignment also increases peak pressures across the subtalar joint, predisposing it to subtalar arthritis.18 The goal of medial fixation in talus fractures is to prevent varus and extension from occurring. This is typically a 2.0 or 2.4 mm plate. Metzger MJ, Levin JS, Clancy JT. Follow-up visits with radiography should occur at 2 and 6 weeks.Once out of plaster, mobilization is started. Federal government websites often end in .gov or .mil. Along the spectrum of injury, increasing displacement presupposes that there is more subtalar and tibiotalar osteochondral injury. Posteromedial approach for open reduction and internal fixation of talar process fractures. Vallier HA, Nork SE, Benirschke SK, Sangeorzan BJ. Controversy exists in the ideal treatment of lateral process fractures. The posterolateral approach of the talus involves making an incision just lateral to the Achilles tendon and developing an interval between the peroneal muscles and flexor hallucis. One must not damage the blood supply to the talus. The https:// ensures that you are connecting to the Talar neck fractures occur with axial load and a foot with muscles in tension holding the foot in a rigid position. Posterior talus fractures are treated through a posteromedial approach utilizing the interval between the flexor hallucis longus and the Achilles tendon.21 Excessive medial retraction should be avoided to prevent injury to the medially located neurovascular bundle. This is an open access journal, and articles are distributed under the terms of the Creative Commons Attribution-NonCommercial-ShareAlike 4.0 License, which allows others to remix, tweak, and build upon the work non-commercially, as long as appropriate credit is given and the new creations are licensed under the identical terms. The peroneal artery and the saphenous nerve should be protected during this approach. The anteromedial approach avoids these two neurovascular bundles and provides access to the medial talus and surrounding joints. What are the treatment options if I develop arthritis?If arthritis develops in one or more joints after a talus fracture, it can be treated with medication, braces, injections, and activity modification. After reduction is achieved and provisionally held, a small 2.0 mm plate is slid over the K-wires. There also is a chance that the bone cannot be put back to its original state, a complication called malunion. A data search using PubMed was performed with the keywords "talus" and "fracture.". Careers, Unable to load your collection due to an error. A poor reduction was an articular or neck mismatch, a step-off or gap of >3 mm, or neck angulation of >5.28 Analysis of the subtalar joint can also use to rate the quality of the reduction. J Bone Joint Surg Am. Early complications occurred in eight patients. HHS Vulnerability Disclosure, Help You can expect to have some degree of pain and stiffness after treatment. No financial conflict of interest results for this review article. Fractures and fracture-dislocations of the talus Surgery of the Foot and Ankle; pp. These situations are extremely challenging and careful clinical evaluation, radiological evaluation for the onset of AVN and posttraumatic arthritis, patients age, demands, should be considered for appropriate planning of surgery. Vallier HA, Reichard SG, Boyd AJ, Moore TA. Organize in-house training events for your surgical staff, Hand Distal phalanges revision published. Additional screws are inserted into the plate by removing a K-wire and replacing it with a screw. The posterior tibial artery has branches medially. Our CT image shows comminution of the inferior talus. Assessment of ankle and hindfoot stability and joint pressures using a human cadaveric model of a large lateral talar process excision: A biomechanical study. The purposes of the present study were to characterize these fractures, to describe one treatment approach, and to evaluate the clinical, radiographic, and functional outcomes of operative treatment. The talus, the second largest tarsal bone, has distinctive imaging characteristics and injury patterns. The importance of this lies in getting a perfect reduction for definitive fixation. The arrow points to a simple fracture of the talar neck, which is less common. Sneppen O, Christensen SB, Krogsoe O, Lorentzen J. Fracture of the body of the talus. The talus is second largest tarsal bone. Sangeorzan BJ, Wagner UA, Harrington RM, Tencer AF. Associated talar neck fractures and open fractures more commonly result in osteonecrosis or advanced arthritis. Update on talar fracture patterns: A large level I trauma center study. The artery of the tarsal canal constitutes the single major arterial supply to the body of the talus. Left and right arrows move across top level links and expand / close menus in sub levels. Marsh JL, Saltzman CL, Iverson M, Shapiro DS. 1-3 However, the fractures' incidence ranks second in all tarsal bone fractures following the calcaneal fractures. PMID: 27241385 DOI: 10.1016/j.ocl.2016.03.008 Abstract This review article provides an overview of talus fractures. in their series of 26 patients found a 50% incidence of AVN. These vessels are well-protected extraosseous, lying within the superior portion of the tarsal canal, and is reinforced by external anastomoses with the anterior tibial and peroneal systems. Talar fracture surgery is needed if the bone has shifted or broken through skin, if the nerves or blood vessels are damaged, or if there is an uneven cartilage surface in the ankle or subtalar joints. The use of a medial or lateral malleolar osteotomy [Figure 5] is more popular and an alternative to the standard anteromedial or anterolateral approach to the talus. Surgical treatment of talar body fractures. INTRODUCTION. Open talar neck injuries or other foot and ankle pathology often are part of a spectrum of injury. found that in patients with significant talar compression, 50% of patients had ankle osteoarthritis; if the talus exhibited a shearing pattern of injury, the incidence of posttraumatic arthritis in both the ankle and subtalar joints was 41%. Plate fixation is applicable in a wide variety of talus fractures, especially where there is comminution, to hold bone grafts in place, or even to maintain surface congruity in cases of comminution. Isolated process fractures and osteochondral fractures can be treated with a direct surgical exposure and internal fixation or arthroscopic reduction.1, Clinical photographs showing approaches (a) Anteromedial approach (b) Anterolateral approach (c) Medial approach (d) Lateral approach, Talar body fracture operated by medial approach and medial malleolar osteotomy (a) Clinical photograph showing skin condition at the time of presentation (b) computed tomography view in axial, coronal and sagittal sections showing talar body fracture (c) Clinical photograph showing medial approach (d) Preoperative X-ray ankle joint anteroposterior and lateral views showint talar body fracture (e) C-arm pictures of medial malleolar osteotomy, temporary fixation with k-wire, (f) Intraoperative Canale Kelly view (g) Postoperative X-ray ankle joint anteroposterior and lateral view showing fixation of talar body medial malleolar osteotomy fixation, (a) Preoperative X-ray ankle joint lateral view showing talar body fracture with extrusion posteriorly (b and c) Intraoperative photographs showing dual medial and posterior approach (d) Postoperative X-ray anteroposterior and lateral views showing fixation of talar body and medial malleolar osteotomy. As such they receive support for travel and housing to meetings of the respective groups. In previous studies, talar body fractures were not differentiated from other fractures of the talus, and the majority of them were treated nonoperatively.13 Interestingly, some authors have advocated primary fusion of the tibiotalar and subtalar joint in comminuted talar body fractures.13, Sneppen et al. Rammelt S, Zwipp H. Talar neck and body fractures. The arrow on the image indicates a simple fracture of the talar neck. National Library of Medicine The talus lies. AP and mortise views allow visualization of the talar dome as well as the lateral process, particularly osteochondral injuries and body fractures in the sagittal plane. Ten of the twenty-six patients who had a complete set of radiographs had development of osteonecrosis of the talar body. Weight-bearing is advanced after union is achieved, 8 weeks in simpler fractures and may take as long as 12 weeks in more comminuted injuries. Plate application follows the standard principles already reviewed with other plating techniques including anatomic reduction, provisional K-wire fixation, sliding the plate over K-wires, and carefully replacing the wires with rigid screw fixation. Twenty-three (88%) of twenty-six patients had radiographic evidence of osteonecrosis and/or posttraumatic arthritis. The .gov means its official. To avoid this, Thordarson recommends the use of neutralization (noncompression) screws for cases with comminution at the fracture site. This often requires surgical approaches for debridement and fixation of these fracture types. . in their series reported their series of 11 fractures of the talar body of which 9 underwent initial ORIF to restore articular congruity, 1 was treated with ankle spanning external fixation and primary tibiocalcaneal fusion in 1 patient. Talar neck fractures can be classified by the Hawkins Classification. A nearly anatomical reduction was defined as a 1 mm to 3 mm step-off of any fracture fragment or slight varus angulation (5). Comminuted talar neck fractures: A mechanical comparison of fixation techniques. Many authors agree that initial degree of fracture displacement is an important risk factor for osteonecrosis. Talus fractures are rare orthopedic injuries. Rotation is assessed medially, and if correct, a K-wire is advanced along the medial side of the talus. Splinting, followed by short leg casting for 6 weeks until fracture union should be undertaken.9,14 Full weight bearing is allowed at the time of complete radiographic union, usually after 810 weeks. Most surgeons will place a tourniquet on the leg above or below the knee. The remaining isolated talar body fracture patterns consisted of sagittal shear, coronal shear, and avulsion fractures.12 CT scan of the talus with thin cuts (1.5 mm) in the coronal and frontal planes helps in planning the surgical approach. Five of these ten patients experienced collapse of the talar dome at a mean of 10.2 months after surgery. The blood supply to the talus is very compromised with a fracture dislocation scenario. The deltoid branch of the posterior tibial artery must be protected. Sneppen et al. Treatment of talar body fractures is based on restoring the joint integrity of the tibiotalar and subtalar joints.13,19,20,21 The accurate restoration of a congruent articular surface is therefore important to minimize the risk of this complication. In addition, AP view of the foot allows visualization of the talonavicular joint in that plane.10 Lateral view of the ankle allows good visualization of the talar neck fractures. The most significant obstacle to proper reduction of talar body fracture is adequate exposure and these traditional surgical approaches often fail to achieve adequate exposure of the talar body, especially in the case of complex talar body fractures. They concluded that results in talar body fractures are directly related to the severity of the initial injury and emphasized that if subluxation and articular damage to the subtalar and talotibial joints occurred at the initial injury, long term prognosis is poor.3 Arthritis in the ankle and subtalar joints can occur in the absence of AVN of the talus and joint incongruity. Future research will determine whether modern treatment algorithms will decrease complication rate and improve patient outcome. (a) X-ray lateral view of ankle joint showing talar body comminuted fracture (b) Peroperative photographs showing lateral and medial approach being used for fixation (c) Postoperative X-rays anteroposterior and lateral views showing talar body fixed with mini fragment plate and medial malleolar osteotomy fixed with two screws. Fortin PT, Balazsy JE. Arthroscopic reduction and internal fixation (ARIF) of a comminuted posterior talar body fracture: Surgical technique and case report. Immediate possible complications from talar surgery include wound healing problems, excess swelling, and infection. Closed injuries also are usually associated with severe swelling and may have elements of internal degloving, which increases the risk for wound healing complications and infections.7, Clinical photographs showing variation in presentation (a) Deep abrasion on anterolateral aspect of ankle (b) Internal degloving of skin (c) Large lacerated wound on anterolateral aspect ankle, Open fractures occur frequently, accounting for 20%25% of injuries, with a greater incidence of fractures become more displaced [Figure 3]. Plates may be used as spring plates to hold key segments in position. 2021 Jun 4;6(2):24730114211012691. doi: 10.1177/24730114211012691. It is ideal to maintain the ankle in a dorsiflexed position to ensure bony reduction of the talar dome and minimize anterior scar tissue formation. K-wires may be used as joysticks and to stabilize a mobile fragment [Figure 8]. If the fracture was sufficiently stabilized with the plates and screws, you may be placed into a removable boot that will allow you to start moving the ankle to combat stiffness and to bathe. and transmitted securely. A Comparative Study Using Fluorescent Confocal Microscopy and Flow Cytometry to Evaluate Chondrocyte Viability in Human Osteochondral Allografts. All patients with a history of both an open fracture and osteonecrosis experienced collapse. Most talar neck fractures present with comminution of the dorsal and medial aspect of the neck of the talus. Epub 2019 Jan 15. The images demonstrate a medial distractor with a patient under general anaesthetic with maximum muscle relaxation. K-wires are inserted into the distal portion of the talus both medially and laterally. The surgical plan should include a direct well planned surgical exposure to the fracture and allow for direct reduction and fixation, avoidance of soft tissue complications by allowing sufficient time for soft tissue edema to subside, eliminating unnecessary soft tissue dissection. The medial malleolar osteotomy is performed by extending the anteromedial approach to provide access for the osteotomy. Ebraheim NA, Patil V, Owens C, Kandimalla Y. In addition fractures of the talar body are difficult to identify adequately due to the overhang of the tibial plafond anteriorly and posteriorly and are often missed.3. They are all connected through a sling of vessels that lie within the sinus tarsi. These fractures are commonly associated with subtalar dislocation and/or posterior body . The ankle and foot must be well-aligned for proper function. Fractures of the body of the talus were associated with the highest incidence of degenerative joint disease of both the subtalar and ankle joints.6 A study by Vallier et al. Medial malleolar osteotomy for exposure of complex talar body fractures. Gomes de Sousa RJ, Teixeira de Oliveira Massada MM, Gonalves Pereira MA, Gonalves Costa IM, da Costa E Castro JF. Talar neck fractures occur infrequently. (e and f) Fluoroscopic anteroposterior and lateral views showing Fracture fixation consisted of a mini fragment plate due to both size and comminution of the lateral process fragment, Talar neck fractures account for 50% of talus fractures.12 Plate fixation for talar neck fractures has been well described.5,13,14,15 In more severe talar neck fractures, comminution is typically present both dorsally and medially along the dominant fracture line. X-ray imaging of the other foot is helpful for comparison.The lateral talar neck is usually not as comminuted as the medial side and can be reduced using fracture interdigitations and screw or plate fixation in a compression mode. Because the talus is important for ankle movement, a fracture often results in substantial loss of motion and function. Talar neck fractures: Results and outcomes. Revascularization can be achieved by good surgical reduction and stable internal fixation. Talar neck fractures are relatively uncommon but potentially devastating injuries with often life-altering sequelae. CT examination can be helpful when there is any question about displacement or requirements for debridement of the subtalar joint. Fractures of the talus are quite rare and account for about 3% of all foot fractures. Your talus bone is the bottom part of the ankle joint. This will lead to more decisions about further investigation and other forms of treatment.Plain x-rays may be all that is required if the fracture is undisplaced. The fractures on the lateral side are simple, and on the medial side multifragmentary. If severe comminution exists, the plate will also assist in holding the comminuted fragments in correct position. the contents by NLM or the National Institutes of Health. Bethesda, MD 20894, Web Policies Recreating the overall shape of the talus is imperative to functional outcome. Effect of percutaneous and arthroscopically assisted osteosynthesis of talar body fractures. However, severe comminution or bone loss are scenarios where locking fixation may be beneficial. To ensure an anatomic reduction, fractures of the neck must be exposed from the lateral and medial side. However, these specific projections have lost importance with the generous use of computed tomography (CT) scanning in cases of talar fractures.9. 5. Screws are then placed in the plate, completing fixation. They also found high rates of posttraumatic arthritis of the ankle and subtalar joints with 95% of patients having moderate or severe complaints. Use of Ilizarov Device to Gain Early Range of Motion in the Treatment of Pediatric Talus Body Fractures: A Series of Four Cases and Literature Review. BMC Musculoskelet Disord. (a and b) Anteroposterior and lateral radiographs of ankle joint showing a lateral process talus fracture after a motorcycle accident. Ideally, depending on the bone quality, integrity of fixation, and extent of soft tissue injury, early range of motion exercise is initiated to minimize stiffness. If the fracture is displaced, then it is often associated with other hindfoot injuries. The dorsalis pedis and peroneal artery supply the neck and the lateral third. In undisplaced fractures, full range of motion is usually achieved rapidly.Gait training is initiated with physiotherapy, as required, at 6-8 weeks. Radiologic evaluation of talar body fractures should always include a CT scan, as plain radiographs may underestimate the degree of articular injury.11 Dale et al. Talar neck fractures: Anatomic considerations for posterior screw application. Debridement of subtalar joint Low rates of malunion have been associated with the use of plates in comminuted neck fractures.13,17, Fixation of the medial side in talar neck fractures is necessary. Some patients will require physical therapy. This view allows the visualization of tibiotalar articulation, subtalar articulation, and talar navicular articulation. These features have an impact on treatment and may have a negative effect on the result. Screws need to be countersunk deep to the cartilage, or headless screws may be used.10 Lateral comminuted fractures need plate fixation [Figure 8] to avoid collapse and secondary malunion [Table 3]. (i-k) Intraoperative fluoroscopic views of ankle showing films demonstrating the reduction including provisional fixation with K-wires, as well as a final fixation with plates and screws. The content is not intended to substitute The neck is the narrow region between head and body. Unfallchirurgie (Heidelb). Once the extensor digitorum brevis is split longitudinally and retracted, one exposes the lateral aspect of the talar neck.Most talar neck fractures result from a medially directed force. However, no such results have been reported in the management of talar fractures with articular involvement.23 The currently available literature regarding ARIF of talar fractures is very limited to few case reports. eCollection 2021 Apr. They occur as a result of high-velocity trauma and are therefore associated with considerable soft tissue damage. Optimal treatment relies on an accurate understanding of the injury and the goals of treatment are the restoration of articular surface and axial alignment. Tab will move on to the next part of the site rather than go through menu items. The bone pieces are then held in position with temporary pins or clamps and the positioning is checked with an X-ray. Nonunion after talar neck or body fractures is rare, occurring in <5%. in their series of 21 patients with talar body fractures 18 underwent closed treatment, and three underwent open reduction and internal fixation (ORIF). Articular fragments are disimpacted and reduced by assessing the undersurface of the talus for congruity. St Louis (MO): Mosby; 1999. This aids in both management planning and can determine the risk of avascular necrosis (AVN). They described talar body fracture like the one in which the fracture line on the inferior surface extends into the subtalar joint.5. Jr. (1978). Snowboard, wakeboard, dashboard? The clinical outcome was based on the American Orthopaedic Foot and Ankle Society (AOFAS) ankle-hindfoot scoring and the excellent outcome was achieved in 4 patients, good in 6, fair in 4, and poor in 5.3 Lindvall et al. [12,13] They are commonly the result of high-energy trauma and are associated with other bony and soft . official website and that any information you provide is encrypted Federal government websites often end in .gov or .mil. If it is painful then many of the same treatments for arthritis may be indicated, including fusion surgery. If you need medical advice, use the "Find a Surgeon" search to locate a foot and ankle orthopaedic surgeon in your area. Dale JD, Ha AS, Chew FS. Nonweight bearing is necessary until union is achieved. (a and b) Mortise and lateral radiographs of ankle joint of a 44-year-old female showing a comminuted talus fracture with associated dislocation as a result of a motor vehicle collision. The subtalar joint is directly below the ankle joint and is responsible for most of the side-to-side motion of our foot. J Bone Joint Surg Am. Despite the high incidence of arthritis (90%), the authors remained optimistic, that only three of eleven patients had osteonecrosis, which is attributed to early anatomic reduction and fracture stabilization.6 Ebraheim et al. Most wounds will take about 2-4 weeks to heal safely, but this can take much longer if there were traumatic wounds, or if the patient has diabetes or smokes. Adelaar RS. Contact characteristics of the subtalar joint: The effect of talar neck misalignment. The body of the talus is supplied almost exclusively from its posteromedial aspect. 8600 Rockville Pike distinguished talar neck and body fractures by inspecting the fracture line on the inferior surface. However, for certain fractures such as minimally displaced fractures or very simple neck fractures, it can be used as the sole approach. Nondisplaced shearing-type talar body fractures. Smith CS, Nork SE, Sangeorzan BJ. Note the deltoid branches of the posterior tibial artery and the artery of the tarsal canal. On postoperative radiographs, the quality of reduction in AP and lateral views could be assessed according to the criteria proposed by Lindvall et al. Perera A, Baker JF, Lui DF, Stephens MM. The overall infection rates range between 3% and 8%.9 While superficial wound edge necrosis usually heals with rest and antiseptic dressings, deep soft tissue infections require radical debridement of all infected and necrotic tissue, copious lavage, occasionally hardware removal, external fixation, continuous drainage (if possible with vacuum-assisted systems), and the administration of antibiotics. official website and that any information you provide is encrypted Treatment outcome of major fractures of the talus. 8600 Rockville Pike HHS Vulnerability Disclosure, Help The artery of the tarsal canal coming from branches off of the posterior tibial artery supply most of the talar body.The peroneal artery has the least contribution laterally. Controversies in treating talus fractures. A talus fracture is a break in one of the bones that forms the ankle. The content of FootCareMD, including text, images, and graphics, is for informational purposes only. It is most important not to damage the deltoid branches which arise posteromedially and supply the medial two thirds of the talar body. Frawley PA, Hart JA, Young DA. The fixation used is mini-fragment 2.4 mm and 2.7 mm screws. However, if this fracture is part of the spectrum of talar neck injuries which presents with . Talar surgery puts the talus bone back together as best as possible. Pseudo os trigonum sign: Missed posteromedial talar facet fracture. This is an open access journal, and articles are distributed under the terms of the Creative Commons Attribution-NonCommercial-ShareAlike 4.0 License, which allows others to remix, tweak, and build upon the work non-commercially, as long as appropriate credit is given and the new creations are licensed under the identical terms. It is important to counsel patients regarding these devastating injuries and their poor prognosis and potential complications. A line diagram showing blood supply of Talus. A posteromedial approach to the body of the talus would destroy its blood supply. FOIA Organize in-house training events for your surgical staff, Hand Distal phalanges revision published. An external fixator or distractor may be placed from the fibula to the calcaneus to improve visualization. Although talar fractures account for less . The site navigation utilizes arrow, enter, escape, and space bar key commands. The treatment of complex fractures of the talus. Skin incisionThe incisions here are based on the deep talar anatomy which lies underneath the extensor digitorum brevis.The incision is based on the fourth metatarsal and lines up with this bone. Medial malleolar osteotomy is the most common osteotomy performed for reduction of complex talar body fractures.2 It is performed more often on the more comminuted side to allow direct access to the fracture fragments. Ohl et al. If it does develop, it is not always painful. Splinting, followed by short leg casting for 6 weeks until fracture union should be undertaken. Talar neck fractures and rates of avascular necrosis. Urgent surgical debridement should be undertaken. All surgeries come with possible complications, including the risks associated with anesthesia, infection, damage to nerves and blood vessels, and bleeding or blood clots. Inclusion in an NLM database does not imply endorsement of, or agreement with, Clinical outcome of fractures of the talar body. The indication and use of plates in fixation of talus fractures are reviewed. Smoking affects your bodys ability to heal the broken bone as well as the surrounding tissues. Clinically, talar body fractures present with soft tissue swelling, hematoma, deformity, and restriction of motion. The surgical incision is essentially a sinus tarsi approach and runs from the just below the tip of the fibula distally for approximately 23 cm parallel to the sole of the foot and along the axis of the fourth metatarsal. In unconscious patients with extensive soft tissue damage compartment syndrome should be ruled out.9. You may have a short stay in the hospital depending on the severity of the fracture and other injuries. Mini fragment plating along the extraarticular portion of the posterior talus best addresses the comminution frequently seen in these injuries. The anterolateral approach is usually employed in combination with the anteromedial approach to gain access to any displaced talar neck fracture. Talar neck fractures: results and outcomes. AVN can occur with any injury depending on the severity of the fracture. Inclusion in an NLM database does not imply endorsement of, or agreement with, The head articulates with the navicular bone anteriorly. Nondisplaced talar neck: AVN Risk 0-15%: Type2: Displaced neck fracture with subtalar dislocation or subluxation: AVN Risk 20-50% . Background: However, Lindvall et al. Talar neck fractures are classified into one of four types ( Fig. and transmitted securely. Treatment of comminuted talar neck fractures with use of minifragment plating. Vallier HA, Reichard SG, Boyd AJ, Moore TA. Lindvall et al. Daniels TR, Smith JW. The incidence of AVN is almost certainly dictated by the fracture pattern and its disruption of the intrinsic blood supply to the talus. Care should be taken not to overlook talar fractures in multiply injured or polytraumatized patients. [Fractures of the talar neck and body : An overview]. Federal government websites often end in .gov or .mil. 2. The cervical and the interosseous talocalcaneal ligaments occupy the sinus tarsi. Would you like email updates of new search results? Foot fellow's review. sharing sensitive information, make sure youre on a federal 8600 Rockville Pike Once skin and fascia are incised, one encounters the fracture hematoma which should be evacuated in order to expose the underlying infero-medial aspect of the neck, and the fracture. The arthroscopic approach depends on the fracture pattern with anterior arthroscopy typically indicated in fracture involving the anterior two-thirds of the talus and in longitudinal fractures. Two less significant sources were the superior neck vessels from the anterior tibial artery and the posterior tubercle branches of the posterior tibial and peroneal arteries.4, One possible mechanism of injury leading to fracture of the body of the talus is a fall from a height, producing an axial compression of the talus between the tibial plafond and the calcaneum.3 Sneppen et al. An official website of the United States government. Emergency reduction Emergency actions The high-energy displaced fractures of the talar neck with, or without, dislocation of the talar body, often present with severe soft-tissue injuries, including open fractures, or both. The artery of the tarsal canal coming from branches off of the posterior tibial artery supply most of the talar body.The peroneal artery has the least contribution laterally. AO teaching video: Application of a Lower Leg Circular Cast. Elgafy H, Ebraheim NA, Tile M, Stephen D, Kase J. Fractures of the talus: Experience of two level 1 trauma centers. It is imperative that no <2 points of fixation are in the fracture at all times to prevent loss of reduction. Seventeen of twenty-six patients had posttraumatic arthritis of the tibiotalar joint, and nine of twenty-six had posttraumatic arthritis of the subtalar joint. Fractures of the posterior portion of the talar body are amenable to plate fixation. If the talar neck fracture is undisplaced and all joint surfaces are in perfect alignment, then nonoperative treatment is a rational choice. More severe neck fractures may have comminution both medially and laterally. reported 25% malunion rates in their series of talar body fractures31 [Table 5]. Early JS. Multiple surgical approaches [Figure 4] are described that include anteromedial approach, posteromedial approach, anterolateral approach and posterolateral approach and sometimes the fracture pattern may warrant a dual approach [Figures [Figures55 and and6].6]. Indications The anterolateral approach is usually employed in combination with the anteromedial approach to gain access to any displaced talar neck fracture. Branches from the dorsalis pedis supply the talar head and most of the dorsal talar neck. Attiah M, Sanders DW, Valdivia G, Cooper I, Ferreira L, MacLeod MD, et al. They found that medial side talar body fractures, is typical of supination trauma (compression or shear type), whereas a lateral side fracture is due to pronation or pronation-external rotation trauma (compression fracture).5, It is important to differentiate talar body fractures from the neck of talus fracture due to the difference in management and the prognosis. The incision can be extended proximally if an additional malleolar osteotomy is required. Inspite of high rates of arthritis of the ankle and subtalar joints, it is the consensus opinion to manage all talar body fractures with anatomic reduction and internal fixation. Organize in-house training events for your surgical staff, Hand Distal phalanges revision published. This, however, is unusual as most talar neck fractures present with at least some displacement.CT examination is very helpful whenever there is any question about displacement, or requirement for debridement of the subtalar joint. Talus fractures are rare orthopedic injuries. Sands AK, White C, Blankstein M, Zderic I, Wahl D, Ernst M, et al. Unable to load your collection due to an error, Unable to load your delegates due to an error. for professional medical advice, diagnoses or treatments. The peroneal artery has branches laterally. A talar fracture is a break in the talus bone that often involves both of these important joints. Surgical treatment of talar body fractures. 2023 Jun;126(6):485-497. doi: 10.1007/s00113-023-01330-z. Department of Foot and Ankle Surgery, Arthroscopy, Ganga Hospital, Coimbatore, Tamil Nadu, India, 1Department of Orthopaedics, Ganga Hospital, Coimbatore, Tamil Nadu, India. The subtalar joint is assessed from the lateral (Ollier) approach for residual step-offs, or fracture distraction.9 Body fractures can be in a coronal plane, sagittal plane, or crush injuries.15 The sagittal plane fracture can be fixed with screws placed medial to lateral [Figure 5]. Other studies have also shown successful treatment of and in the management of osteochondral lesions of the talus. Grob D, Simpson LA, Weber BG, Bray T. Operative treatment of displaced talus fractures. Methods: Twenty-three patients had a concomitant talar neck fracture. Careers, Unable to load your collection due to an error. Before Such fractures typically are the result of high-energy trauma and are characterized by displacement, comminution, and soft-tissue injury. Plate fixation of talar neck fractures: Preliminary review of a new technique in twenty-three patients. An official website of the United States government. The anteromedial approach is most commonly used and is done by making an incision medial to the tibialis anterior tendon. The second image demonstrates the talar neck reduction with tibiotalar distraction still maintained. Does smoking affect my outcome?Yes. The advantage of Arthroscopy is that it enables the identification of intraarticular loose bodies, cartilage injuries, and transchondral defects that are radiologically insignificant.24 Case reports on talar body fractures have reported Satisfactory outcomes at the end of 1-year followup.25 It is ideally indicated for 2-part fracture without severe soft tissue damage. As talus fractures are often associated with significant soft tissue trauma,1,2,3 the timing of definitive fixation using plates has to be considered with caution. A plate along the medial talar neck bridges the zone of comminution and prevents shortening. Long-term evaluation of seventy-one cases." J Bone Joint Surg Am 60(2): 143-156. Therefore, if the body has to be exposed, one utilizes an osteotomy of the medial malleolus. All neck fractures ideally require both medial and lateral incisions to assess rotation and obtain an accurate reduction. A second rolled blanket is placed under the mid portion of the tibia to flex the knee. Before The initial evaluation should be done with foot, and ankle radiographs and computed tomography is often done to analyze the extent of the fracture, displacement, intraarticular extension, comminution, and associated fractures. Using the reduction clamp to control the distal segment, the fracture line on the lateral aspect of the neck of the talus is reduced and a K-wire is advanced to provide provisional fixation. official website and that any information you provide is encrypted FOIA 2022 Dec 14;23(1):1090. doi: 10.1186/s12891-022-05991-6. Complications, secondary procedures, and the ability to return to work were evaluated at a minimum of one year. 11. A talar fracture is a break in the talus bone that often involves both of these important joints. They are all connected through a sling of vessels that lie within the sinus tarsi. Bohler angle; Common Accessory . An official website of the United States government. Talar neck fractures are high energy injuries to the hindfoot that are associated with a high incidence of talus avascular necrosis. When it is obtained, it is done incidentally in a patient who has pain, swelling, and inability to bear weight, but otherwise normal initial radiographic imaging is sufficient to make a diagnosis. Please enable it to take advantage of the complete set of features! Specific applications including fractures of the lateral process, posterior fractures, extreme comminution, bone grafting, and spring plating to hold key segments are reviewed in this article. Any of these complications may require another procedure to correct. Plates can be used to provide length stable fixation, prevent rotation, and hold the graft in position [Figure 3]. These two exposures ensure adequate visualization for reduction and fixation. Conclusions: Fractures of the body of the talus are uncommon and poorly described. 13 If the fracture . To prevent further soft-tissue damage, urgent closed reduction is mandatory. Talar neck fractures: Results and outcomes. ARIF helps in anatomical reduction and fixation with interfragmentary screws under direct vision. Baumhauer JF, Alvarez RG. It is an important point for blood supply entry into the medial talus. Satisfactory results have been achieved in arthroscopically assisted fixation of ankle fractures. Further, anatomic fracture reduction and rigid internal fixation help to restore the intraosseous anastomoses, which is essential for fracture healing and revascularization of the talar body. Talar neck displaced fractures have been historically considered surgical emergencies due to their frequent association with peritalar joint dislocations or subluxations. Goals of treatment include restoration of articular surface and axial alignment followed by rigid fixation of fracture to maintain alignment until fracture unites. Washers are not needed with screw fixation as the talus is dense bone and is inadequate to address the small comminuted fragments often seen in these fractures. The talonavicular joint is best assessed with a dorsoplantar view of the foot with the tube tilted 20 caudally. Talar body fractures have various classifications, and these classifications does not help in making treatment choices or predict outcome.6 The commonly used Sneppen's classification divided these fractures into five types7 [Figure 2], and Fortin classified them into three types8 [Table 1]. found 38% incidence of AVN and Lindvall et al. Your surgeon will monitor the incisions and bone healing for the first several weeks after surgery. Talar neck fractures: results and outcomes Authors Heather A Vallier 1 , Sean E Nork , David P Barei , Stephen K Benirschke , Bruce J Sangeorzan Affiliation PMID: 15292407 Abstract Background: Talar neck fractures occur infrequently and have been associated with high complication rates. National Library of Medicine Furthermore, arthroscopy may be combined with ORIF for comminuted fractures that require removal of loose bodies. Fracture dislocations can easily compromise the blood supply to the body of the talus and lead to avascular necrosis. A line diagram showing Sneppens classification of talar body fractures, In addition to these classifications, fractures of the talar dome can also be further classified into sagittal, coronal, transverse, or segmental fractures.7 Boyd and Knight have classified talar body fractures according to the plane of the fracture line. Range of motion is initiated after the sutures are removed. The content of FootCareMD, including text, images, and graphics, is for informational purposes only. Bethesda, MD 20894, Web Policies The hardware is only removed if it causes irritation to the flexor hallucis longus, which is rare. The high-energy displaced fractures of the talar neck with, or without, dislocation of the talar body, often present with severe soft-tissue injuries, including open fractures, or both. J Orthop Trauma. If medial talar neck comminution is very severe with a resultant bone defect, then primary bone graft might be considered.The lateral plate will fit along the lateral neck and process of talus. When the positioning is correct, the surgeon will place permanent screws and plates across the fracture. Which side is injured is obvious by looking at the foot that it is swollen and deformed. sharing sensitive information, make sure youre on a federal In the hours to days after surgery, the foot may swell considerably after a talar fracture. Knowledge of a wide variety of fixation techniques will assist the treating surgeon in managing these rare fractures. According to Dr. Schwartz, percutaneous fixation should only be performed on truly nondisplaced fractures to provide early range of motion and avoid late displacement. The high variability of talar fractures and their relatively low incidence together with the high percentage of concomitant injuries makes treatment of these injuries a challenge to the surgeon. Once that has been carried out, even only to the point of improving the position, if not completely reducing the fracture, one can begin preoperative planning of further and definitive care.If a satisfactory reduction of the fragments can not be achieved, or if one is dealing with an open fracture, then an urgent operative intervention is mandatory.This image shows a talar neck fracture dislocation with medial displacement and comminution before reduction. The bone is exposed with one or two incisions and the broken pieces are realigned. This often requires surgical approaches for debridement and fixation of these fracture types. Up and Down arrows will open main level menus and toggle through sub tier links. Ohl et al. After surgery, it can be retained to facilitate recovery of the soft tissue and prevent an excessively high intra-articular pressure. If these treatments are unsuccessful, your foot and ankle orthopaedic surgeon may discuss additional surgery with you. Results: Even in severely comminuted fractures attempts should be made to restore at least the tibiotalar joint.11 The early reports available in the literature have made little mention about talar body fractures and the outcomes of their treatment. It remains controversial whether talar neck fractures require emergent treatment. Fifty-six patients with fifty-seven talar body fractures who had been treated operatively during a sixty-seven-month period at a level-1 trauma center were identified with use of a database. Non-weight bearing with a below-knee cast is continued for 6-8 weeks. With the K-wires placed appropriately and with image intensification verifying accurate reduction, a plate is contoured both medially and laterally through the anteromedial and anterolateral combined approaches.The medial plate will fit along the medial neck with screws into the head and the body, leaving the mid-portion overlying the comminution free of screws.With this fixation, medial talar neck shortening or collapse will not occur. The integrity of the talus is essential for the normal function of the ankle, subtalar, and midtarsal joints. Then the incisions are closed and the foot is placed into a cast or splint. Fractures and fracture-dislocations of the talus Surgery of the Foot and Ankle; pp. More frequently, a small T plate is placed on the lateral process in inverted fashion to provide additional buttress to the fracture components to prevent late collapse [Figure 1]. Vallier HA, Nork SE, Barei DP, Benirschke SK, Sangeorzan BJ. However, timing of fixation did not appear to affect the outcome, union, or prevalence of AVN. Postoperatively, it is crucial to encourage early range of motion of the great toe, as the flexor hallucis longus is prone to scarring down at the posterior aspect of the talus, resulting in markedly restricted motion. Loose cancellous graft in the subtalar joint will interfere with future joint function and potentially damage to the articular surface from particulate debris. (c and d) Fluoroscopic view showing the patient was treated with closed reduction and external fixation at presentation. Locking plates are seldom needed in talus fractures due to the dense nature of the bone in the talus. The .gov means its official. It supplies the middle one-half to two-thirds of the body directly [Figure 1]. 2015 May;29(5):210-5. doi: 10.1097/BOT.0000000000000297. The most dreaded complication is septic necrosis of the talar body requiring partial or total talectomy, temporary placement of antibiotic polymethylmethacrylate-beads, and secondary tibiocalcaneal fusion. Donahue J, Shofoluwe A, Krautmann K, Grau-Cruz E, Becher S, Bruggers J. reported 87% neck and body fracture of the talus with the highest incidence for Hawkins type II with no type I neck fracture. 2003 Sep;85(9):1716-24. doi: 10.2106/00004623-200309000-00010. Occasionally, a fragment will contain a combination of extraarticular and articular surface. 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Generous use of plates in fixation of these important joints, it is not to... Arrows will open main level menus and toggle through sub tier links injury patterns tissue damage and complications... Medial malleolus comminution and prevents shortening plate, completing fixation Human osteochondral Allografts 20 caudally AO! < 2 points of fixation did not appear to affect the outcome, union or! Flow Cytometry to Evaluate Chondrocyte Viability in Human osteochondral Allografts go through items. Sometimes patients may present with soft tissue envelope should guide the foot and ankle pp. Motorcycle accident the graft in position the bones that forms the ankle foot. Characterized by displacement, comminution, and graphics, is for informational purposes only Operative of! Tab will move on to the body of the incisions must be in! To flex the knee Jackson WT wires may be indicated, including text images! The patient was treated with closed reduction is mandatory dictated by the Hawkins Classification talar... Nerve, most of the talus these injuries typically are the restoration of articular surface use... Percutaneous and arthroscopically assisted transfibular talar dome at a minimum of one year Case! If it does develop, it can be extended proximally if an additional malleolar osteotomy is required access for first..., these specific projections have lost importance with the generous use of neutralization ( )... Talar fractures Management Management of osteochondral lesions of the body directly [ Figure 3 ] ( )... Mosby ; 1999 ligaments occupy the sinus tarsi 10.2 months after surgery it... Retained to facilitate recovery of the articular reductions in the talus, patient. Rammelt S, Ogawa K, Usami N. Classification of talar body 2.0 plate! A range of motion is initiated after the sutures are removed adequate visualization for reduction and fixation. Surgeon may discuss additional surgery with you screws for cases with comminution of the talus back. That initial degree of fracture to maintain alignment until fracture union should be ruled out.9 arthritis may used... Side multifragmentary completing fixation found high rates of posttraumatic arthritis emergent reduction of the talus motion of our.. Orif for comminuted fractures that require removal of loose bodies Fluoroscopic view showing the was. Jorgensen NB, Lutz M. Arthroscopic treatment of and in the talar neck fracture surgery treatment of talus. And space bar key commands, including text, images, and nine of twenty-six patients who had complete! Arrow on the affected foot to form your ankle joint and obtain an accurate of. Intra-Articular pressure, Owens C, Blankstein M, Zderic I, Ferreira L, MacLeod MD et... The incidence of talus fractures for reduction and internal fixation nonoperative treatment is break. This view allows the visualization of the subtalar joint.5 ( Fig energy injuries to the talus is very compromised a! Moore TA after reduction is mandatory, Ferreira L, MacLeod MD, et al directly below knee... Rates in their series of 26 patients found a 50 % incidence of AVN is almost certainly dictated the! Head articulates with the anteromedial approach avoids these two exposures ensure adequate visualization for reduction and fixation normal function the. Evidence of osteonecrosis of the superficial peroneal nerve, most of the most common long-term complications after talar neck body! Deltoid branches which arise posteromedially and supply the talar neck injuries which with. From the dorsalis pedis supply the neck of the soft tissue damage compartment syndrome should be protected high injuries! Da Costa E Castro JF percutaneous and arthroscopically assisted fixation of ankle joint a... Is a break in the plate by removing a K-wire and replacing it a! Search results is swollen and deformed an important risk factor for osteonecrosis space bar key commands in. Physiotherapy, as required, at 6-8 weeks other injuries talus receives branches from the malleolus... Quite rare and account for about 3 % of patients having moderate or severe complaints future will! Lindvall et al or two incisions and bone healing for the normal function of the body to... Dp, Benirschke SK, Sangeorzan BJ commonly associated with fractures of the plate will also assist in the... For ankle movement, a K-wire and replacing it with a fracture dislocation scenario from! Require emergent treatment are then put through a sling of vessels that lie within the sinus tarsi mm plate and., Mekhail AO, Salpietro BJ, Mermer MJ, Jackson WT made in splint! Distractor may be combined with ORIF for comminuted fractures that require removal of loose bodies and... And to stabilize a mobile fragment [ Figure 3 ] 6 weeks.Once out of plaster, mobilization is.. For definitive fixation: 143-156 exposure of complex talar body a talar fracture is undisplaced and all joint are! Osteotomy of the talus receives branches from the dorsalis pedis and peroneal artery the... Rolled blanket is placed under the mid portion of the twenty-six patients had radiographic evidence osteonecrosis... Are removed fractures following the calcaneal fractures soft-tissue damage, urgent closed reduction fails must... With peritalar joint dislocations or talar neck fracture surgery muscle relaxation the respective groups then it is imperative that no < 2 of... ( Fig wound healing problems, excess swelling, hematoma, deformity, and nine of twenty-six posttraumatic. And reduced by assessing the undersurface of the fracture site alone runs the risk of shortening the neck the... Medially placed distractor or external fixator may aid in direct visualization of the side-to-side motion our. This bone fractures or after native treatment with traditional bone setters:1090. doi 10.2106/00004623-200309000-00010!
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