Review Question - QID 218603

This patient sustained an open talar neck fracture with talar body extrusion. Given the wound contamination, degree of soft tissue injury, and uncontrolled diabetes, the most appropriate option is formal irrigation and debridement, temporizing ankle-spanning external fixation, and delayed definitive fixation.

The talus has multiple articulations, prompting over 50% of its surface area to be made of articular cartilage. This leaves relatively little surface area available for vascular inflow and thus a risk of osteonecrosis after trauma. Talar neck fractures are categorized based on the Hawkins classification which correlates with an increased risk for subsequent osteonecrosis. The general consensus is to fix talar neck fractures unless the fracture is truly nondisplaced. Given its many articulations, the quality of reduction is the most important predictor for long-term outcomes. There has been a general trend toward performing delayed operative fixation due to the risk of wound complications and infection if fixed acutely. In low-risk patients with amenable fracture patterns, definitive fixation can be considered in the acute setting (i.e. simple fracture pattern, percutaneous screw fixation). However, in an open fracture with a contaminated wound in an uncontrolled diabetic patient, temporizing fixation would be most appropriate. Definitive fixation can be performed once the traumatic wound and soft tissue swelling appear amenable.

Vallier provided a comprehensive review of talus fractures, with an emphasis on talar neck and body fractures. She discusses a high rate (up to 75%) of early complications with open fractures including wound dehiscence, skin necrosis, and infection. She contrasts these outcomes to delayed definitive surgical fixation, which is associated with much lower complication rates (2-10%). She concludes that definitive procedures are best deferred until adequate resolution of swelling roughly 1-3 weeks after injury.

Vints and colleagues reviewed the long-term outcomes of talus fractures at their institution. They found that the outcomes of operative treatment were dependent on the occurrence of osteoarthritis postoperatively, the type of fracture, and the quality of fracture reduction. They emphasized that the only modifiable factor in patient-reported outcomes was the quality of reduction and therefore is of utmost importance. They similarly found that delayed surgery was associated with overall better outcomes with lower osteoarthritis rates.

Figure A shows a clinical picture of this patient’s open talar neck fracture with talar body extrusion. Figures B and C shows AP and lateral imaging of the same injury after reduction was performed in the emergency department. There is an appreciable medial malleolar fracture, which is an associated injury commonly encountered. Figure D shows the post-reduction sagittal CT imaging with fracture displacement and air associated with the open injury. The patient underwent temporizing external fixator placement that evening. Illustration A shows post-operative imaging after this patient underwent open reduction internal fixation 2 weeks later.

Incorrect Answers:
Answer 1: Tetanus administration and IV antibiotics should be administered in the emergency department. However, this open fracture with talus body extrusion should undergo operative irrigation and debridement.
Answer 2: Definitive Steinman pin fixation would not allow for compression at the fracture site and is not the ideal fixation construction. Further, it would be less than ideal to leave large pins exposed from the skin of a contaminated, open fracture. As shown in Illustration A, percutaneous screw fixation allows for definitive closure and compression of the reduced talus.
Answer 3: Similar to Steinman pin fixation, this simple talus fracture pattern should be treated with open reduction internal fixation with compression to facilitate primary bone healing. Further, given the high risk for wound and infection complications in this patient, acutely placing definitive hardware would not be advisable.
Answer 5: Acute TTC nailing for an open talar neck fracture is not indicated.