1. Fracture Talus
Dr.Jayant Sharma.
M.S, DNB, MNAMS
CONSULTANT ORTHOPADICS AND
SPORTS MEDICINE.
www.drjayantsharma.com

2. TALUS
 IInd most common tarsal fracture
 60% coverage by articular cartilage
 no tendon / muscle attachments
Tenuous blood supply
 90% of motion of foot / ankle
 Body, neck, head, lat. and post.
processes

3. Blood supply
 Branches from post. and
ant. tibial arteries,
 Perforating peroneal
arteries
 Anastomoses in sinus tarsi
and tarsal canal
 inferior sling
 Capsular and ligamentous
supply

4. Fractures
 Head
 Neck – 50%
 Body ± Dislocation
 Lat process
 Post Tab

5. Issues
 How to diagnose
 Reduction
 Lat process and post tub
 Osteochondral fracture
 Vascular complication
 Avascular necrosis

6. HOW TO DIAGNOSE?
 X-ray – AP / Mortice
(enlocated / assoc #)
 - Lateral (#, subtalar joint)
 - Neck view (Canale &
Kelly)
 CT – comminution,
alignment, subluxation

7. Talar neck fracture
 Mechanism – hyperdorsiflexion or direct axial
load e.g MVA, fall from height, “aviators
astragalus”
 Posterior capsule ruptures , talar neck impacts
on distal tibia , vertical fracture.
 Foot subluxes forwards > talar body in equinus.
Or
 Pushed postero-medially out of mortice sits
between medial malleolus and tendo Achilles.

8. Talar neck fracture
 Osteonecrosis depends on degree of
displacement.
 Undisplaced disrupt intra-osseous
branches of sinus tarsi / tarsal canal
arteries
but major sling remains intact.
 If Displaced above -- disrupt dorsalis
pedis branches to neck.

9. Talar neck fracture
Classification
 Hawkins’ classification
(1970)
 I – undisplaced vertical
fracture
 II – displaced fracture and
dislocated S.T. jt.
 III – above + dislocated
ankle joint
 IV – above + dislocated
talo-navicular joint
(Canale & Kelly, Khazim & Salo)
Associated fractures -
64% (Hawkins,
Lorentzen)
Medial malleolus.
19-28% Calcaneum.
10% Metatarsal
fractures.
Distal tibio-fibular joint
diastasis.

10. Talar neck fracture
Treatment
 Best results with prompt,
accurate anatomical
reduction & maintenance
 Type I – absolutely no
displacement / ST
incongruency
 BK cast 6 -12 weeks
(NWB 6 weeks)

11. Talar neck fracture
Treatment
 Type II – prompt closed
reduction, traction,
plantarflexion,
 correct varus /valgus
 Xray – in equinus
 BK cast in equinus
(6weeks), cast for up to
3 months & 2 weekly
 Internal fixation
(antegrade fixation)

12. Type II Talar neck Fracture
Treatment
 Avoid multiple attempts at
closed reduction.
 Open reduction -
 Antero-medial or antero-lateral
approach
 Cannulated screws (4.5/ 6.5
mm) (titanium)retrograde or
antegrade– beware penetration
talo-navicular joint NWB cast 6-
12 weeks

13. Talar neck fracture
 Treatment
 Type III – 25% open
 Closed – prompt reduction, closed
reduction often impossible
 ?Arthroscopic assisted reduction
Open reduction – postero-medial or anteromedial
approach
 Leave deltoid ligament fibres intact
 Osteotomise / fractured medial malleolus

14.  Internal fixation –
 cannulated compression
screws (avoid
comminuted medial neck)
 Delayed primary closure
at 5-7 days
 BK cast NWB 3 months
Treatment

15. Treatment
 Type IV –
manage as for
III, and reduce
talo-navicular
joint(usually
heals in cast)
 Prognosis related
to displacement of body
Talar Neck Fracture

17. Fractures neck
with subtalar
dislocation and
post dislocation
of Talus
Emergency
Immediate
Reduction
1942 – Boyd &
Knight – Red and ST
Arthrodesis
1957 - Bohler –
Open reduction If
close Red fails-
1959 - Allgower –
open red and lag
screw
1962 - Watson
Jones –open
reduction If close
Red fails
1963 - Mc Keever
Red and Triple
Arthrodesis

19. Posterior displacement of body needs open
reduction

20. Points to remember
ORIF may not be
easy. Be prepared
to do medial
Malleolus
Osteotomy – use
of Calcaneal pin
Save Talus – Be
prepared to face
AVN

21. Talar neck fracture – Complications
 Skin Necrosis and Infection
 Prompt reduction, debride the open wounds
and leave open.
 Persisting infection > radical debridement of
body.
 Best results from excision of sequestered talus
and tibio-calcaneal fusion.

22. Talar neck fracture
Malunion
 Varus – lateral weight bearing Subtalar joint stress
secondary arthritis (osteotomy and bone graft)
 – Dorsal displacement of head -- reduced dorsiflexion,
pain (excise dorsal talar beak)
Delayed Union / Non-union
 Delayed union common, but Non-union rare (0-4%)
 Poor blood supply, limited periosteum on neck
 No healing at 12 months > Cortico-cancellous bone
graft

23. Blair Fusion-- Advantages
Position of foot unchanged
Backward displacement not
required
Foot & Ankle relationship not
disturbed
Limb not shortened
Preserves some Sub- Talar Motion

25. Talar neck fracture
Complications- Osteonecrosis
 Degree varies with
injury, but still need
early, accurate
reduction to reduce its
secondary effects.
 Type I : 0-13%
 Type II : 20-50 %
 Type III : 83-100%

26.  X-ray – increased radio-
density talar body
 Later – collapse of
subchondral bone,
reduced joint space,
fragmentation of body
 MRI clearly defines
presence and extent of
involvement.
Talar neck fracture -
Osteonecrosis

27. Talar neck fracture -
Osteonecrosis
 “Hawkins’ sign” – high
sensivity, moderate
specificity.
 At 6-8 weeks, disuse
atrophy because NWB.
 AP X-ray- subchondral
atrophy in dome, implying
vascularity

28. Talar neck fracture - Osteonecrosis
 Primary goal is union, which still occurs,
therefore continue NWB, even if no Hawkins
sign.
 Once united, still need up to 3 years before
revascularisation /PTB brace/NWB
If dome collapse and pain, identify joint/s
involved and arthrodese.
Usually tibiotalocalcaneal fusion.

29. Talar body fracture
 20% talar fractures
 Classification - Sneppen (1977)
 I - Osteochondral dome fracture
 II – Coronal, sagittal, horizontal Shear
fractures
 III – Posterior process fractures
 IV – Lateral process fractures
 V – Crush fractures

31.  1% talar fractures
 Mechanism:
 – dorsiflexion / inversion anterolateral lesion
 – plantarflexion / inversion posteromedial
lesion
 Often not visible on Xray > persistent pain
weeks after “sprain” +/- locking
 Bone Scan - sensitive, but not specific
 MRI – identification and classification
Osteochondral Dome
Fracture

32.  - Classification
 Anderson (1989)
 I – subchondral trabecular compression
 II – incomplete separation of fragment
 IIa – subchondral cyst
 III – fragment not attached, but remains in
 normal position
 IV – displaced fragment loose within joint
 Pritsch arthroscopic grading of cartilage
condition (firm, soft, frayed)
Osteochondral Dome
Fracture

33. Osteochondral Dome
Fracture
Treatment
 Incidental finding at ORIF > remove or fix
 Incidental finding on Xray > observe
 Symptomatic
– Stage I / II - BK cast 6 - 12 weeks NWB
– If still symptomatic > soft > leave NWB or drill
cartilage
frayed > debride & curette
– If >1 cm and subchondral bone fix with absorbable
pin

34. Osteochondral Dome
Fracture
 -Treatment
 Stage III – prolonged NWB versus early surgery
 - Arthroscopy > debride fragment & curette
underlying bed
 Stage IV – remove loose body, if bed covered by
fibrocartilage > leave, if frayed debride to
bleeding subchondral bone / mosaicplasty
 Results - 50% have pain on activity
 (Pettine & Morrey, Angermann & Jensen)

35. Shear Fractures of Body
 Fracture line extends into dome, or
into subtalar joint.
 MVA, fall from height. Generally
poor long-term results. Higher risk
of osteonecrosis.
 AP / lateral / mortice / CT
 Undisplaced -- BK cast until radiol
signs of healing
 Thordarson (2001) > 1mm+
displacement -- ORIF via medial
malleolar osteotomy
 Complications > osteonecrosis –
NWB up to 2 years, arthritis 75%

36. Lateral Process Fracture
Snowboarder’s Fracture
25% talar fractures
 May extend into subtalar joint (bigger fragments)
 Mechanism – dorsiflexion and inversion.
 AP / mortice / CT
 Undisplaced – BK cast NWB 6 weeks
 Displaced >2mm / 1cm fragment > ORIF
 Prognosis – often present with nonunion or arthritis
months after injury. Best results with undisplaced
fracture or accurat reduction. May need late excision
of non-united fragments
or subtalar fusion

37. Posterior Process Fracture.
Lateral tubercle fracture
 – Mechanism : inversion or
compression
(extreme equinus)
 – DDx: os trigonum
 – Xray : lateral, Bone Scan
 – Treatment : undisplaced –
BK cast 4-6 weeks
 – Persistent pain and
stiffness – excise non-united
 fragment

38. Posterior Process Fracture
Medial tubercle fracture
 – Rare, pronation in dorsiflexion (athletes)
 – Present late with medial pain and swelling
 – Xray : lateral, avulsed medial fragment on
AP
 – Undisplaced : BK cast 6 weeks
 – Displaced : ORIF especially if ST joint
involved.
 – Non-union : persistent pain > excise
fragments

39. Crush fracture
 Uncommon, high complication rate.
 Usually significant displacement, and subluxed
subtalar /
ankle joints
 C. T
 Treatment : anatomical reduction via anteromedial
arthrotomy +/- osteotomy medial malleolus, pins /
screws
for large articular fragments. Bone graft / substitute.
 If stable fixation, early ROM post-op
 Complications : osteonecrosis, arthritis, malunion

40. Fractured Head of Talus
 Uncommon.
 Usually involves talo-
navicular joint.
 Mechanism :
compression of
head, plantarflexed foot.
 Xray : AP / lateral /
oblique –
check navicular and
calcaneo-cuboid joint.

41. Fractured Head of Talus -
Treatment
 Undisplaced : BK cast NWB 6 - 12 weeks, then
medial arch support 3-6 months
 Displaced : anatomical reduction via anteromedial
approach. Excise comminuted fragments.
 Complications : persisting subluxation and
arthritis.
Talo-navicular pain may improve with
firm longitudinal arch support.
 If fails, then arthrodesis talonavicular joint or
entire midfoot (test with local anaes. injections)

42. Association with
Fracture calcanceum
Talus may be
subluxated or
fractured along
with fracture
calcanceum - a very
rare injury.
 Total Talectomy
 Tibio Calcaneal
Fusion

43. Points to Remember
 Earlier the reduction the better are the
chances of success
 Subtalar subluxation and dislocation should
not be missed
 Deforming force is the key to reduction
 Do not hesitate to put calcaneal pin
 Immobilisation for longer period
 Appreciate the jeopardised blood supply the
foot
Treat As Emergency

44.  Recognise the Collapse of talus
 BLAIR fusion is the Best.
 Tibio calcaneal fusion to be
undertaken as a last resort
 Rare fractures to be kept in mind