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Talus Fracture

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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
    • 18-25% of talar fractures are open[1]
    • Up to 64% are associated with other fractures
    • Common in men, early to mid 30s[2]
  • Prevalence
    • Account for between 0.1% and 2.5% of all fractures[3]
    • Account for 3-5% of foot and ankle fractures
  • Location/ Description
    • Talar neck accounts for 45-50% of all talus fractures[4]
    • Body fractures make up 13-23% of talus fractures [5]
    • Head accounts for 3-10% of talar fractures
    • Lateral process about 0.8%[6]

Talar neck fracture in axial, coronal and sagittal planes.

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


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]
Nondisplaced fracture through the body of the talus

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
    • Reported range of 4% - 100% incidence rate (mean 49%)[20]
    • Another study looking at talar neck fractures found an overall rate of 68%[21]
    • Subtalar arthrosis was most common (42%), followed by tibiotalar arthrosis (18%)
  • Avascular Necrosis
    • Second most common complication[22]
    • Risk based on Hawkins classification of talar neck fractures: Type I (0%), Type I (42%), Type I (91%)
    • 2013 review found all-comer AVN incidence rate of 33%[21]
    • Rate higher in neck (55%) than in body (27%)[23]
    • Likely higher in open fractures than closed fractures
  • Infection
    • Small case series of open fractures showed deep infection rate of 25%[24]
    • A large systematic review found the overall deep infection rate of 21%[21]
  • Malunion/ Nonunion
    • Halverson found the overall rate of nonunion at 5%, malunion at 17%[21]
  • Need for more surgery
    • Halvorson: secondary surgery was needed in 19% for 715 fractures[21]
    • Displaced fracture rate need for secondary surgery as high as 37%[25]
    • 10 Year rate for second surgery approaches 50%[25]
  • Complex Regional Pain Syndrome
  • Venous Thromboembolism

See Also


References

  1. 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.
  2. 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.
  3. 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.
  4. Shakked, RJ, Tejwani, NC. Surgical treatment of talus fractures. Orthop Clin North Am. 2013;44(4):521–528.
  5. Ziran, BH, Abidi, NA, Scheel, MJ. Medial malleolar osteotomy for exposure of complex talar body fractures. J Orthop Trauma. 2001;15(7):513–518.
  6. 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.
  7. 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.
  8. 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.
  9. 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.
  10. 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.
  11. https://surgeryreference.aofoundation.org/orthopedic-trauma/adult-trauma/talus/neck-multifragmentary/definition
  12. https://radiopaedia.org/cases/69282
  13. 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.
  14. Hawkins, LG . Fractures of the neck of the talus. J Bone Joint Surg Am. 1970;52(5):991–1002.
  15. 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.
  16. 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.
  17. 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.
  18. Rammelt, S, Zwipp, H. Talar neck and body fractures. Injury. 2009;40(2):120–135.
  19. Vallier, HA . Fractures of the talus: state of the art. J Orthop Trauma. 2015;29(9):385–392.
  20. Dodd, A, Lefaivre, KA. Outcomes of talar neck fractures: a systematic review and meta-analysis. J Orthop Trauma. 2015;29(5):210–215.
  21. 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
  22. . Bykov, Y . Fractures of the talus. Clin Podiatr Med Surg. 2014;31(4):509–521.
  23. 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.
  24. 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. 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.
Created by:
John Kiel on 18 June 2021 08:04:28
Authors:
Last edited:
3 October 2022 23:55:02
Categories:
Lower Extremity | Trauma | Leg | Ankle | Fractures | Acute