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Average 4.4 of 63 Ratings
A 35-year old male is involved in a fall from height and present with the isolated injury shown in Figures A and B. The body of the talus is extruded medially through a large linear open wound. Along with irrigation and debridement, what is the most appropriate definitive management of this injury?
Reimplantation of the talar body followed by cast immobilization
Reduction of talar body, fracture fixation with smooth Steinman pins, and spanning fixator placement
Talar body allograft with internal fixation to native talar head
Fragment removal, antibiotic spacer placement and external fixation
Reduction of native talar body and ORIF of talar neck fracture
Select Answer to see Preferred Response
The patient is presenting with a displaced talar neck fracture with extrusion of the talar body. Reimplantation of the talar body and ORIF of the talar neck fracture is the most appropriate treatment.
Talar extrusions are rare injuries and are caused by high energy mechanisms. Complete dislocation without a concomitant fracture is extremely rare. The talus is prone to dislocation as there are no muscular attachments. These injuries need to be treated with anatomic reduction and internal fixation to prevent avascular necrosis and post traumatic arthritis.
Smith et al. investigated the clinical results and functional outcome after reimplantation of the extruded talus. They concluded that salvage and reimplantation of the talus is a relatively safe procedure with only 2 of the 27 patients developing an infection. No association was found between outcome and associated talar fracture.
Van Opstal et al. reported on two cases of talar extrusions following high energy injuries and reviewed the associated literature. Both cases were treated with wound I&D, reduction and external fixation. After 1 year they had pain free ROM with no signs of AVN or arthritis. Review of the literature showed that anterolateral dislocations are more common than anteromedial. Total talar dislocation is thought to be the endpoint of maximum pronation or supination injuries.
Figures A and B show an extruded talar body in the setting of a Hawkins III talar neck fracture. Illustration A shows a clinical photo of an extruded talus.
Answer 1: Displaced talar neck fractures should not be treated in a cast, especially open fractures
Answer 2: Definitive treatment of this injury is most effectively accomplished with formal ORIF. Steinman pin fixation is not adequate, even in the presence of an external fixator.
Answer 3: There is no data supporting removal of fragment and use of allograft over use of native talar body
Answer 4: There is no data supporting removal of the fragment. The associated references support retaining the fragment.
Smith CS, Nork SE, Sangeorzan BJ.
J Bone Joint Surg Am. 2006 Nov;88(11):2418-24. PMID: 17079399 (Link to Abstract)
Smith, JBJS 2006
Van Opstal N, Vandeputte G.
Acta Orthop Belg. 2009 Oct;75(5):699-704. PMID: 19999887 (Link to Abstract)
Van, ACTAB 2009
HPI - Fell from the stairs.
What is the best treatment option?
Halvorson JJ, Winter SB, Teasdall RD, Scott AT
J Foot Ankle Surg. 2013 Jan-Feb;52(1):56-61.. PMID: 23153783 (Link to Abstract)
Halvorson, F 2013
Please rate question.
Average 3.0 of 24 Ratings
A 25-year-old man presents one year after undergoing open reduction and internal fixation of the fracture seen in Figure A. Current radiographs demonstrate a united fracture with no evidence of ostenecrosis, subtalar or tibiotalar arthritis. Physical exam is notable for ambulation on the lateral border of the right foot with hindfoot varus, midfoot supination and diminished subtalar motion compared with the contralateral side. Which of the following is an option for reconstruction of this patient's deformity?
Total ankle arthroplasty
Lateral calcaneus closing wedge osteotomy
Calcaneal neck opening wedge osteotomy
Talar neck opening medial wedge osteotomy
The most common position of talar neck malunion is varus and this deformity can lock the subtalar and transverse tarsal joints leading to diminished motion and ultimately subtalar arthrosis. Medial opening wedge osteotomy of the talar neck has been described to restore the anatomy of the talus and preserve hindfoot motion.
Daniels et al performed a biomechanical study of hindfoot motion following medial osteotomy and varus malalignment of the talar neck. The authors found a direct correlation between the degree of varus malalignment and diminished forefoot and subtalar motion, and caution against compressive fixation of the medial talus in the presence of comminution.
Monroe and Manoli present a case report of talar neck malunion and describe their technique for osteotomy of the talar neck with insertion of a tricortical iliac crest bone graft to correct the deformity. They found a significant improvement in the AOFAS ankle-hindfoot score and no evidence of osteonecrosis with follow-up greater than 4 years.
Huang and Cheng retrospectively review their results with anatomic reconstruction of the talar neck in 9 patients who presented a minimum of four weeks after the initial injury with a malreduced or neglected talar neck fracture. They found favorable outcomes with delayed reconstruction as determined by the AOFAS ankle-hindfoot score at an average follow up of 53 months, however note that six patients subsequently developed radiographic hindfoot arthrosis.
Figure A demonstrates a lateral radiograph of a comminuted talar neck fracture with subluxation of the subtalar joint.
Answer 1: Total ankle arthroplasty is reserved for patients with end-stage tibiotalar arthritis. This patient has an intact and functional tibiotalar joint
Answer 2: Lateral calcaneus closing wedge osteotomy would correct some hindfoot varus, however would not address the talar neck deformity leading to diminished motion.
Answer 3: Calcaneal neck opening wedge osteotomy would exacerbate the patient's deformity
Answer 5: Triple arthrodesis would be not be a viable option in a patient with a preserved tibiotalar and subtalar joint.
Daniels TR, Smith JW, Ross TI.
J Bone Joint Surg Am. 1996 Oct;78(10):1559-67. PMID: 8876585 (Link to Abstract)
Daniels, JBJS 1996
Monroe MT, Manoli A 2nd.
Foot Ankle Int. 1999 Mar;20(3):192-5. PMID: 10195299 (Link to Abstract)
Monroe, FAI 1999
Huang PJ, Cheng YM
Int Orthop. 2005 Oct;29(5):326-9. PMID: 16094539 (Link to Abstract)
Huang, INTORT 2005
Average 3.0 of 35 Ratings
Varus malalignment after a talar neck fracture with medial comminution causes a decrease in what motion?
Varus alignment at the talar neck results in a decrease in subtalar eversion before impingement occurs. Varus talar neck alignment can cause a fixed internal rotation position of the midfoot as the navicular follows the talar head. This can lead to a more rigid hindfoot which is specifically manifested as a decreased eversion range of motion.
Illustration A is a diagram of the hindfoot that shows how malalignment can affect the hindfoot.
Herscovici et al review the appropriate management of complex ankle and hindfoot injuries in this instructional course lecture.
Daniels et al performed a cadaveric study where they osteotomized the talar neck and then studied ankle motion with and without removal of a medially based wedge of bone. They found that subtalar eversion was specifically decreased.
Sanders et al found that secondary reconstructive procedures following talar neck fractures were most commonly performed to treat subtalar arthritis or misalignment.
Herscovici D Jr, Anglen JO, Archdeacon M, Cannada L, Scaduto JM.
J Bone Joint Surg Am. 2008 Apr;90(4):898-908. PMID: 18381329 (Link to Abstract)
Herscovici, JBJS 2008
Sanders DW, Busam M, Hattwick E, Edwards JR, McAndrew MP, Johnson KD
J Orthop Trauma. 2004 May-Jun;18(5):265-70. PMID: 15105747 (Link to Abstract)
Sanders, JOT 2004
Average 2.0 of 30 Ratings
A 30-year-old patient underwent open reduction internal fixation of a talar neck fracture 8 weeks ago. His current radiographs demonstrate a subchondral radiolucency of the dome of the talus. What is the next most appropriate course of action?
Injection of bone cement into the talus to prevent further avascular necrosis
Ankle arthroscopy to address this osteochondral lesion
Continued observation as the vascularity to the talus is intact
A subchondral radiolucency of the talar dome after a talar neck fracture is known as the "Hawkins sign" and is a well-described radiographic indication of viability of the talar body. Rockwood and Green state "by the 6th-8th week, if the patient has been non-weight-bearing, diffuse atrophy is evident by radiographs. An AP radiograph of the ankle reveals the presence or absence of subchondral atrophy in the dome of the talus. Subchondral atrophy excludes the diagnosis of avascular necrosis." Tezval et al in a retrospective review showed that a subchondral lucency seen on the AP radiograph was a good indicator of talus vascularity following fracture. They state it is unlikely that AVN will develop at a later stage after injury if a Hawkins sign was present. Illustration A shows the characteristic appearance of a Hawkins sign and subchondral sclerosis.
Tezval M, Dumont C, Stürmer KM.
J Orthop Trauma. 2007 Sep;21(8):538-43. PMID: 17805020 (Link to Abstract)
Tezval, JOT 2007
Average 3.0 of 23 Ratings
A 29-year-old male sustains the isolated lower extremity injury shown in Figure A. During open reduction, what structure must be kept intact in order to protect the remaining blood supply to the talar body?
Anterior talofibular ligament
Figure A represents a type 3 Hawkins talar neck fracture. A type 3 injury is defined as a displaced fracture of the talar neck with dislocation of body of talus from both the subtalar joint and the tibiotalar joint. In these injuries, the talar body fragment typically rotates around intact deltoid ligament fibers to lie in soft tissues with the fracture surface pointing laterally and cephalad. Often, the deltoid branch of the posterior tibial artery, which lies between the leaves of the deltoid ligament and supplies up to 1/2 of the medial talar body, is the only remaining blood supply. Therefore, the deltoid ligament must be preserved to lower the risk of avascular necrosis. When performing a medial malleolar osteotomy, the deltoid ligament must remain in continuity with the malleolus to prevent disruption of the blood supply.
The review article by Fortin et al discusses talar blood supply, injury mechanisms and classifications, and treatment options. They state that the main artery to the body of the talus is the artery of the tarsal canal, which is a branch of the posterior tibial artery. The peroneal and anterior tibial artery also contribute branches to the talus.
Illustration A and B show the arterial network of the talus.
Fortin PT, Balazsy JE.
J Am Acad Orthop Surg. 2001 Mar-Apr;9(2):114-27. PMID: 11281635 (Link to Abstract)
Fortin, JAAOS 2001
Average 4.0 of 27 Ratings
A 34-year-old female is involved in a motorcycle crash. She sustains a talus fracture with associated dislocation of the subtalar joint and maintained congruence of the tibiotalar and talonavicular joints as shown in Figure A. The fracture has healed and she now has symptomatic impingement of the dorsal surface of the talus on the distal tibia and restriction of ankle dorsiflexion. What is the most likely deformity causing these symptoms?
Combined varus and plantar malunion
Isolated varus malunion
Isolated valgus malunion
Isolated dorsal malunion
Isolated plantar malunion
Figure A displays a Hawkins Type 2 talar neck fracture. (Hawkins classification shown in Illustration A). Malunion after inaccurate reduction of talar neck fractures has a reported incidence as high as 32%, with varus malunion occurring most frequently. Dorsal malunion can occur when the body is not properly derotated during reduction and the head fragment remains dorsal to the body. Dorsal malunion can lead to symptomatic impingement of the dorsal surface of the talus on the distal tibia and restriction of ankle dorsiflexion. Canale found that 3 of the 4 patients with dorsal malunion improved following dorsal beak resection of the talar neck. Patients with varus malunion have decreased subtalar range of motion(especially eversion), walk with the foot internally rotated, and often complain of excessive weight bearing on the lateral border of the foot.
Level 4 evidence from Canale and Kelly found that varus malunion occurred most frequently in Hawkins type 2 fractures that had been treated in a closed manner.
Canale ST, Kelly FB Jr.
J Bone Joint Surg Am. 1978 Mar;60(2):143-56. PMID: 417084 (Link to Abstract)
Canale, JBJS 1978
Average 2.0 of 60 Ratings
A 30-year-old male sustains the injury shown in figure A and undergoes successful open reduction and internal fixation. Which of the following radiographic features is a good prognostic factor for this injury?
Talar dome subchondral lucency
Talar dome subchondral sclerosis
Associated medial malleolus fracture
Talar lateral process fracture
Figure A demonstrates a talar neck fracture. A subchondral talar lucency at approximately 6 weeks postoperatively indicates revascularization of the talus and is a good prognostic factor for this injury (aka Hawkins' Sign and is exhibited by the arrows in Illustration A).
The talar neck blood supply is tenuous and is susceptible to avascular necrosis. The reference by Hawkins classified talar neck fractures and correlated the incidence of avascular necrosis with the degree of displacement and severity of the fracture: Type I = Nondisplaced vertical fractures (AVN 10%). Type II = Displaced with subtalar dislocation/subluxation (AVN > 40%). Type III = Displaced with talar body dislocation (AVN >90%). Type IV = Displaced with talar head subluxation and body extrusion (AVN 100%).
The reference by Canale et al reviewed long term outcomes after ORIF of talar neck fractures, and they found that good or excellent results were seen in only 59%. Salvage procedures such as triple arthrodesis, tibiocalcaneal fusion, and dorsal beak resection of the talar neck all resulted in a high percentage of satisfactory results, but talectomy did not.
J Bone Joint Surg Am. 1970 Jul;52(5):991-1002. PMID: 5479485 (Link to Abstract)
Hawkins, JBJS 1970
Average 4.0 of 26 Ratings
A 47-year-old male sustains the closed injury seen in Figures A and B after failing to land a motorcycle jump. A post-reduction radiograph is seen in Figure C. Which of the following is the most appropriate treatment at this time?
Definitive closed treatment
Addition of percutaneous pins
Open reduction and internal fixation
Primary subtalar arthrodesis
The clinical presentation and imaging studies are consistent with Hawkins II talar neck fracture, which by definition is a displaced talar neck fracture with subtalar dislocation/subluxation. Despite achieving an adequate reduction initially (shown in Figure C), there is no role for closed treatment of these unstable injuries, and the treatment of choice is open reduction and internal fixation.
The referenced article by Bibbo et al describes these injuries: 32% of subtalar joints are irreducible to closed means (half with soft tissue block, half with bony block to reduction), 88% have co-existing injuries of the ipsilateral foot, 89% have radiographic subtalar arthrosis at 5 years (62% symptomatic).
Bibbo C, Anderson RB, Davis WH
Foot Ankle Int. 2003 Feb;24(2):158-63. PMID: 12627624 (Link to Abstract)
Bibbo, FAI 2003
Average 3.0 of 19 Ratings
A 30-year-old male undergoes successful surgical fixation of a displaced talar neck fracture. Which of the following is the most likely long-term complication even after anatomic reduction and stable fixation is achieved?
Tibiotalar and/or subtalar arthritis
Loss of forefoot supination
It is important to counsel patients regarding these devastating injuries and their poor prognosis, as osteonecrosis, subtalar and tibiotalar joint degeneration, and talar collapse are not infrequent.
In a series by Lindvall et al, subtalar joint arthritis was reported as more common than osteonecrosis of the talus at 4 year follow-up after fixation. Osteonecrosis of the talus was the next most common complication following surgery.
The referenced article by Vallier et al reported on mid- to long-term follow-up of this patient population. Ten of the twenty-six patients had development of osteonecrosis of the talar body, but only half experienced collapse of the talar dome. All patients with a history of both an open fracture and osteonecrosis experienced collapse. Seventeen of twenty-six patients had posttraumatic arthritis of the tibiotalar joint, and nine of twenty-six had posttraumatic arthritis of the subtalar joint.
Illustrations A and B show a displaced talar neck fracture.
Vallier HA, Nork SE, Benirschke SK, Sangeorzan BJ.
J Bone Joint Surg Am. 2003 Sep;85-A(9):1716-24. PMID: 12954830 (Link to Abstract)
Vallier, JBJS 2003
Lindvall E, Haidukewych G, DiPasquale T, Herscovici D, Sanders R
J Bone Joint Surg Am. 2004 Oct;86-A(10):2229-34. PMID: 15466732 (Link to Abstract)
Lindvall, JBJS 2004
Average 2.0 of 47 Ratings
HPI - 10 year old patient presents with a painful foot after a fall from height.
The foot is severely swollen and he is unable to bear weight on his affected leg due to significant pain.
What further imaging would you order in this patient?