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Fractures of the Talus:

Current Concepts
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FRACTURES of the TALUS

Subtitle

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INTRODUCTION

• Talus injuries present a diverse, unique set of challenges in

management with a profound impact on the short- and longterm
functional outcomes for the patient
• Complicated by :
• the predominantly articular nature of the bone
• its prominent role in the weightbearing process
• the tenuous blood supply network that perfuses it

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EPIDEMIOLOGY

• Relatively rare
• Account for 0.1% to 2.5% of all fractures, and 3% to 5% of foot and
ankle fractures
• Talar neck are the most common anatomic site for injury and
account for 45% to 50% of all fractures of the talus.
• More common in men than women
• Average patient age early to mid-30s, with a broad range

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CLASSIFICATION title style
of TALAR NECK FRACTURE

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ANATOMY

• Transfers loads from the tibia to the remainder of the foot.

• 3 main structures:
• Body
• Trapezoidal, bordered superiorly by the convex talar dome
• Neck
• No articular cartilage,
• Varus and plantarflexed neck-body angles of 10 to 44 degrees and 5 to 50 degrees, respectively
• Head
• Convex, fully coated in articular cartilage
• Articulates with the navicular bone.
• Supported by the calcaneonavicular (“spring”) ligament that maintains the plantar arch

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ANATOMY

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BLOOD edit Master title style
of TALUS

• The extraosseous blood supply of the

talus is an amalgam of contributions
from :
• Anterior tibial artery
• Posterior tibial artery
• The largest contributor through its branch to
the tarsal canal
• Perforating peroneal artery
• Talar head also gets contributions
from the dorsalis pedis and the artery
of the tarsal sinus
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MECHANISM Master title style
INJURY

Motor vehicle collision (most common)

Fall from height
Pedestrian struck by automobile
Crush injuries
Athletic injuries
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DIAGNOSIS

• 6.9% of talus fractures were undiagnosed at the time of

presentation
• most commonly occurred in lower-energy scenarios such as falls from 1 m,
rotational injuries during the loading phase of rock climbing ascent, and
rotational injuries during community ambulation.

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DIAGNOSTIC Master title style

• The sensitivity for any talar injury is only 74%, with displacement being
the largest driver of radiographic sensitivity.
Plain radiographs • Talar dome osteochondral fracture, lateral process fracture, and
posterior process fracture are the most frequently missed fracture sites

Computed • Gold standard

• Provide information on degree of comminution, articular involvement,
tomography (CT) and surgical planning

Magnetic resonance • Useful for persistent pain after trauma to aid in diagnosis
of peritalar soft tissue injuries and osteochondral injuries
imaging (MRI) such as those in the talar head or dome

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Osteochondral fracture noted on (A) axial and (B) sagittal magnetic resonance images. The
osteochondral lesion is marked with an asterisk

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SURGICAL Master title
INDICATION andstyle
TIMING of FIXATION

• Maintenance of a reduced joint line and stable articulation are key to

short-term functional status and long-term mitigation of post
traumatic arthritis risk
• Nonoperative should only be considered when there are :
• nondisplaced neck and body fractures
• nonambulatory patients
• medically unable to tolerate surgery
• A low threshold for operative treatment should be employed
because unsuccessful closed reduction attempts will lead to further
decompensation to compromised soft tissues.
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SURGICAL Master title
INDICATION andstyle
TIMING of FIXATION

• Contraindication of early open treatment (early multiplantar external

fixation (EF) should be considered):
• severe soft tissue swelling or fracture blisters
• extensive open fracture wounds that limit access to the fracture
• severely comminuted open fracture wounds with gross contamination
• Soft tissue healing precludes conversion of EF to an open articular
and bony reduction and internal fixation (ORIF)

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INDICATION andstyle
TIMING of FIXATION

• Relative contraindication of open reduction and internal fixation

(ORIF) :
• superficial soft tissue infections
• advanced peripheral vascular disease, chronic venous insufficiency (with
skin ulceration)
• systemic immunodeficiency
• noncompliant patients

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INDICATION andstyle
TIMING of FIXATION

• Historically, emergent treatment and fixation was recommended for

talus fractures because of the known risk of osteonecrosis with talar
neck fractures
• Open injuries, as with any other fracture, require emergent
debridement and stabilization
• Closed injuries are amenable to a more situational
approach to surgical timing.
• Delayed fixation is protective of soft tissue complications (wound
dehiscence, skin necrosis, and infection)

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NONOPERATIVE title style
TREATMENT

• Closed reduction and immobilization is a temporizing measure to

relieve the high soft tissue stress delivered by displaced fracture
fragments, and typically requires substantial muscular relaxation
• Nondisplaced fractures of the head and body can be treated by
casting the foot and ankle in a neutral position for 6 weeks
• Partial weightbearing is required for approximately 8 to 10 weeks
until radiographic proof of union of the fracture is obtained.
• Trial of cast immobilization of acute posterior or lateral talar process
fractures of at least 6 weeks is useful, as articular congruity is
typically maintained
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Click to editMANAGEMENT
OPERATIVE Master title style

• External Fixation
• Indication
• used to stabilize a reduced talus fracture
• dislocation when soft tissue injury
• patient medical status preclude safe open reduction and internal fixation
• Sometimes it is necessary to place pin in the talus
• medial safe zone is along the anteromedial neck, proximal to the talonavicular joint and
superior to the tibialis posterior tendon
• Lateral safe zone is a small nonarticular portion of the neck (requires fluoroscopic
localization due to difficulty with reliable palpation )
• Classic deltaframe constructs can be used in stable reductions

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Internal Fixation
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• The mainstay of treatment
• avoid alteration of contact pressures between the ankle and hindfoot articulations
• minimize the risk of osteonecrosis
• talus fractures malunion tolerances are less than 3 degrees
• The goal of fixation methods
• direct anatomic compression of fracture lines without comminution
• maintenance of length and alignment where comminution precludes compressive
forces

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Internal Master title style
Fixation

• Combined anteromedial and anterolateral approaches facilitate maximal

exposure
• An adjunct oblique medial malleolus osteotomy offers additional exposure to the
talar dome, if indicated
• Percutaneous screw fixation of nondisplaced, noncomminuted talar neck and
body fractures can be considered, though strict care to cross the fracture
perpendicularly in the anterior-posterior and superior-inferior planes is necessary
to achieve maximal fragment compression
• Anatomic reduction is best obtained through dual approaches to directly visualize
both the medial and lateral talar neck
• Lag screw fixation confers maximal construct stability, though it sacrifices the
alignment control of plate constructs with or without supplementary lag or
interfragmentary fixation
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Internal Master title style
Fixation

• Intraoperative contouring of
minifragment plating on the lateral
surface of the talus is recommended to
avoid medial shortening and varus
malunion, particularly in cases of neck
shortening greater than 2 mm
• Medial plates have proven to be
potentially symptomatic, screws (most
commonly headless or countersunk) is
often preferred to supplement lateral
plate fixation

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ARTHROSCOPY

• Not suitable as a sole method of fracture visualization and reduction for

large, displaced fragments
• Enables direct visualization of smaller articular fractures that are difficult to
visualize through an open approach and avoids the soft tissue stripping of
an extensile dissection
• Good short-term results in the arthroscopic reduction and fixation of a
coronal talar body fracture that occurred in conjunction with an
osteochondral fracture of the talar dome
• Facilitated earlier rehabilitation, beginning at 15 days postoperatively
• An adjunct method of fracture visualization to assist with an open reduction
for percutaneous screw fixation
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OUTCOME

• Difficult to quantify given the variability of :

• the fracture’s anatomic location
• displacement severity
• associated soft-tissue injuries
• surgical approach
• associated orthopedic and nonorthopedic injuries
• No significant difference in outcomes between talar body and talar neck fractures
• Lateral process fractures showed the best functional outcomes after surgery, when
compared with fractures of any other portion of the talus
• Anatomic union of talar neck and body fractures, without post-traumatic arthritis or
osteonecrosis, yields a satisfactory functional outcome
• Postsurgical complications are poorly tolerated by most patients
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COMPLICATIONS

• Post-traumatic arthritis
• post-traumatic arthritis is
thought to be the most common
• range of 4% to 100% incidence
rate with a mean of 49%
• treatment of post-traumatic
arthritis can be accomplished
through arthrodesis of the
affected joints

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Avascular Master title style
necrosis
• the second most common post-
surgical complication
• rate of osteonecrosis increases with
fracture grade
• overall osteonecrosis rates of 0%,
42%, and 91% for Hawkins types I, II,
and III, respectively
• the rate of AVN in neck fractures
(55%) and body fractures (27%)
• post-traumatic talus AVN is classically
managed with a hindfoot
intramedullary fusion nail
• newer therapies have emerged, such as
vascularized bone grafting and total talus
replacement
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Post-traumatic avascular necrosis of the talar dome after talar neck fracture, as indicated by focal area
of sclerosis. The asterisk indicates the region of avascular necrosis
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INFECTION

• Significant concern given the high rate of (at least) shortterm local
devascularization
• Open fractures were found to have a deep infection rate of 25%
• To minimize infection, should undergo serial debridement until contamination
and soft tissue necrosis has been eradicated
• Closed fractures, the rate of infection is not well reported, but the
estimated overall deep infection rate is 21%
• should be managed when soft tissue swelling has diminished to avoid high
stress and malperfusion of incisional skin flaps

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MALUNION Master title style
NONUNION

• Poorly tolerated by talus fractures

• Anatomic union is the foundation of a satisfactory clinical outcome
• Persistent pain in the absence of infection, arthritis, or necrosis raises
the suspicion of a deviation from a well-aligned talus
• Overall rate of nonunion at 5% and malunion at 17% in a talar neck
fractures
• the rate of overall nonunion is highly variable, with rates ranging from 3% to
20%
• The most common malunion is varus through the talar neck
• treated with a medial-based opening wedge osteotomy of the talar neck
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• Complex regional pain syndrome

• Venous thromboembolic event
• Rare occurences

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PROCEDURES

• Repeat surgical intervention after an index treatment of a talus

fracture can stem from treatment of the aforementioned
complications
• secondary surgery was needed in aprox. 19% of talus fracture
• the incidence of secondary surgery rose from 24% at 1 year after the injury
to 48% after 10 years.

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SUMMARY

• Talus fractures represent a challenging and heterogeneous group of injuries

• Identification and characterization of talus fractures can be difficult with plain radiography,
and 3-dimensional imaging is often necessary
• Anatomic reduction and stable fixation are crucial to preserving lower extremity function
• Open fractures may be treated with external fixation or early fixation with surgical
debridement, depending on soft tissue contamination and the location of traumatic wounds
• Fixation methods range from extensile open plate fixation to limited, percutaneous, and/or
arthroscopy-assisted screw fixation depending on fracture pattern and displacement
• Complications, like post-traumatic arthritis and AVN, can result in a significant decline in
functional status
• Understanding of the bony and vascular anatomy and respect for soft tissues is crucial to
maximizing the likelihood of a successful outcome

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Thank You

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