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Talus Fracture
From WikiSM
Contents
Other Names
- Fracture of Talus
- Talus Injuries
- Snowboarder's Fracture
- Lateral Process of Talus Fracture
Background
- This page refers to fractures of the Talus
History
Epidemiology
- General
- Prevalence
- Account for between 0.1% and 2.5% of all fractures[3]
- Account for 3-5% of foot and ankle fractures
- Location/ Description
Pathophysiology
- General
- Heterogeneous group of injuries to various parts of the bone
- Can be complicated due to (a) significant articular component, (b) significant role in weight bearing and (c) tenuous blood supply
Etiology
- General
- Typically high energy mechanism
- Examples include motor vehicle crash, motor cycle collision, fall from height, crush injury, etc
- Low energy mechanism
- About 7% of cases were delayed or missed due to low energy mechanism[7]
- Examples include fall from 1M, rotational injury
- Lateral process fracture
- High association with snowboarding, hence the term "snowboarder's fracture"
- Talar Neck
- Typically involve high energy mechanism
- High risk of avascular necrosis
Associated Conditions
- Subtalar Dislocation
- Occur in 15% of talar injuries[8]
- Ipsilateral lower extremity fractures are common
Pathoanatomy
- Talus
- 60-70% of bone is articular and covered in articular cartilage[9]
- No muscular attachments
- Responsible for transferring load from tibia to the foot
- Perfused by a tenuous blood supply
Risk Factors
- Sports
- Snowboarding (lateral process)[10]
Differential Diagnosis
- Fractures & Dislocations
- Muscle and Tendon Injuries
- Ligament Injuries
- Bursopathies
- Nerve Injuries
- Arthropathies
- Pediatrics
- Fifth Metatarsal Apophysitis (Iselin's Disease)
- Calcaneal Apophysitis (Sever's Disease)
- Triplane Fracture
- Other
Clinical Features
- History
- Patient should be able to describe an acute injury
- Ankle pain may localize to injury (i.e. lateral process fracture is lateral)
- Patient reports pain, swelling, inability to bear weight
- Physical Exam: Physical Exam Ankle
- Inspection may reveal bruising, swelling, effusion, reduced range of motion
- Tenderness
- Inability to perform gait exam
- Pain can be made worse by flexion/extension of great toe (FHL activitation), especially with posterolateral tubercle fractures
- Special Tests
Evaluation

XR demonstrating significantly displaced talar neck fracture[11]

CT demonstrating comminuted fracture of the talar neck[12]
Radiographs
- Standard Ankle Radiographs
- Initial imaging modality of choice
- Standard views AP, lateral, mortise
- Canale view
- Best view for talus fracture
- Technique: maximum equinus, 15° pronated, xray beam is 75° cranial from horizontal
- Diagnostic accuracy
- Sensitivity 74%, which increases with degree of displacement[13]
- Most frequently missed
- Osteochondral Fracture
- Lateral Process Fracture
- Posterior Process fracture
CT
- Gold standard
- Helps with
- Surgical planning
- Degree of comminution
- Articular involvement
MRI
- Not typically indicated
- Can be used to evaluate soft tissue injuries
Classification
Hawkins Classification of Talar Neck Fractures
- Type I[14]
- Description: No displacement
- Risk of AVN: 0-13
- Type II
- Description: Subtalar joint dislocation
- Risk of AVN: 20-50
- Type III
- Description: Subtalar, tibiotalar joint dislocations
- Risk of AVN: 20-100
- Type IV
- Description: subtalar, tibiotalar, talonavicular joint dislocations
- Risk of AVN: 70-100
Anatomic Classification of Talus Fracture
- Lateral process fracture
- Type 1: Fractures do not involved the articular surface
- Type 2: Fractures involve the subtalar and talofibular joint
- Type 3: Fractures have comminution
- Posterior process
- Posteromedial tubercle: Avulsion of the posterior talotibial ligament or posterior deltoid ligament
- Posteromedial tubercle: Avulsion of the posterior talofibular ligament
- Talar head fracture
- Talar body fracture
Management
Prognosis
- Talar neck fractures outcomes as determined by American Orthopaedic Foot & Ankle Society (AOFAS) ankle-hindfoot score[15]
- Average across all hawkins classification: 76.5 following ORIF
- Type I: 77.0
- Type II: 86.1
- Type III: 68.3
- Type IV: 68.3
- AOFAS score influenced by[16]
- Post traumatic osteoarthritis, average decreased AOFAS score of approximately 9 points
- If patients develops AVN, AOFAS score drops by average of 22 points
- Overall outcome
- Lateral process fractures have best outcome compared to other fracture types[17]
Acute
- Follow ATLS as necessary depending on clinical context
- Closed Reduction
- All cases require emergent closed reduction due to high risk of AVN
- Often requires procedural sedation
- If unable to reduce, needs emergent operative management
- Reduction: Talar neck[18]
- The forefoot is initially maximally dorsiflexed to re-create the initial deformity
- Followed by forced plantarflexion with concomitant distraction of the calcaneus
- Gentle inversion/eversion
- Reduction: Talar body
- Require significant distraction of the subtalar joint
- Direct manipulation of the displaced fragment
Nonoperative
- Indications[19]
- Some patients with nondisplaced body, head, process fractures (< 2 mm)
- Hawkins I Talar Neck Fracture
- Some nonambulatory patients
- Medically unable to tolerate surgery
- Short Leg Cast
- Non weight bearing, neutral for 6 weeks
- Partial weight bearing for up to 10 weeks
- Radiographic trend
- Must trend for proof of union, absence of further displacement
Operative
- Indications
- Talar neck: all displaced fractures (Hawkins II-IV)
- Goals
- Maintain of a reduced joint line
- Stable articulation
- Technique
- External fixation (temporizing)
- ORIF with Kirshner wire Fixation
- Fragment excision
- Arthroscopy has been described
Rehab and Return to Play
Rehabilitation
- Needs to be updated
Return to Play/ Work
- Needs to be updated
Complications
- Ankle Osteoarthritis
- Avascular Necrosis
- Infection
- Malunion/ Nonunion
- Halverson found the overall rate of nonunion at 5%, malunion at 17%[21]
- Need for more surgery
- Complex Regional Pain Syndrome
- Venous Thromboembolism
See Also
- Internal
- External
- Sports Medicine Review Ankle Pain: https://www.sportsmedreview.com/by-joint/ankle/
References
- ↑ Shibuya, N, Davis, ML, Jupiter, DC. Epidemiology of foot and ankle fractures in the United States: an analysis of the National Trauma Data Bank (2007 to 2011). J Foot Ankle Surg. 2014;53(5):606–608.
- ↑ Elgafy, H, Ebraheim, NA, Tile, M, Stephen, D, Kase, J. Fractures of the talus: experience of two level 1 trauma centers. Foot Ankle Int. 2000;21(12):1023–1029.
- ↑ Fournier, A, Barba, N, Steiger, V, et al. Total talar fracture—long-term results of internal fixation of talar fractures. A multicentric study of 114 cases. Orthop Traumatol Surg Res. 2012;98(4)(suppl):S48–S55.
- ↑ Shakked, RJ, Tejwani, NC. Surgical treatment of talus fractures. Orthop Clin North Am. 2013;44(4):521–528.
- ↑ Ziran, BH, Abidi, NA, Scheel, MJ. Medial malleolar osteotomy for exposure of complex talar body fractures. J Orthop Trauma. 2001;15(7):513–518.
- ↑ Perera, A, Baker, JF, Lui, DF, Stephens, MM. The management and outcome of lateral process fracture of the talus. Foot Ankle Surg. 2010;16(1):15–20.
- ↑ Young, KW, Park, YU, Kim, JS, Cho, HK, Choo, HS, Park, JH. Misdiagnosis of talar body or neck fractures as ankle sprains in low energy traumas. Clin Orthop Surg. 2016;8(3):303–309.
- ↑ Barg, A, Tochigi, Y, Amendola, A, Phisitkul, P, Hintermann, B, Saltzman, CL. Subtalar instability: diagnosis and treatment. Foot Ankle Int. 2012;33(2):151–160.
- ↑ Higgins, TF, Baumgaertner, MR. Diagnosis and treatment of fractures of the talus: a comprehensive review of the literature. Foot Ankle Int. 1999;20(9):595–605.
- ↑ von Knoch, F, Reckord, U, von Knoch, M, Sommer, C. Fracture of the lateral process of the talus in snowboarders. J Bone Joint Surg Br. 2007;89(6):772–777.
- ↑ https://surgeryreference.aofoundation.org/orthopedic-trauma/adult-trauma/talus/neck-multifragmentary/definition
- ↑ https://radiopaedia.org/cases/69282
- ↑ Dale, JD, Ha, AS, Chew, FS. Update on talar fracture patterns: a large level I trauma center study. AJR Am J Roentgenol. 2013;201(5):1087–1092.
- ↑ Hawkins, LG . Fractures of the neck of the talus. J Bone Joint Surg Am. 1970;52(5):991–1002.
- ↑ Jordan, RK, Bafna, KR, Liu, J, Ebraheim, NA. Complications of talar neck fractures by Hawkins classification: a systematic review. J Foot Ankle Surg. 2017;56(4):817–821.
- ↑ Lindvall, E, Haidukewych, G, DiPasquale, T, Herscovici, D, Sanders, R. Open reduction and stable fixation of isolated, displaced talar neck and body fractures. J Bone Joint Surg Am. 2004;86(10):2229–2234.
- ↑ Elgafy, H, Ebraheim, NA, Tile, M, Stephen, D, Kase, J. Fractures of the talus: experience of two level 1 trauma centers. Foot Ankle Int. 2000;21(12):1023–1029.
- ↑ Rammelt, S, Zwipp, H. Talar neck and body fractures. Injury. 2009;40(2):120–135.
- ↑ Vallier, HA . Fractures of the talus: state of the art. J Orthop Trauma. 2015;29(9):385–392.
- ↑ Dodd, A, Lefaivre, KA. Outcomes of talar neck fractures: a systematic review and meta-analysis. J Orthop Trauma. 2015;29(5):210–215.
- ↑ 21.0 21.1 21.2 21.3 21.4 Halvorson, JJ, Winter, SB, Teasdall, RD, Scott, AT. Talar neck fractures: a systematic review of the literature. J Foot Ankle Surg. 2013;52(1):56–61
- ↑ . Bykov, Y . Fractures of the talus. Clin Podiatr Med Surg. 2014;31(4):509–521.
- ↑ Vallier, HA, Nork, SE, Benirschke, SK, Sangeorzan, BJ. Surgical treatment of talar body fractures. J Bone Joint Surg Am. 2004;86(suppl 1, pt 2):180–192.
- ↑ Burston, JL, Isenegger, P, Zellweger, R. Open total talus dislocation: clinical and functional outcomes: a case series. J Trauma. 2010;68(6):1453–1458.
- ↑ 25.0 25.1 Sanders, DW, Busam, M, Hattwick, E, Edwards, JR, McAndrew, MP, Johnson, KD. Functional outcomes following displaced talar neck fractures. J Orthop Trauma. 2004;18(5):265–270.